A home health nurse is providing care to an older adult client during the winter. During an in-home visit, the nurse notes that the thermostat is set to 12.8° C (55° F). The client tells the nurse, "I keep the heat set low because I can't afford to pay the bill." Which of the following actions should the nurse take?

Recommend staying at a local shelter until the client can afford the bill.

Contact the local Department of Health and Human Services for the client.

Contact the client's family members to tell them the client's financial status.

Provide the client with written information about the dangers of hypothermia.

Answer and Explanation

The Correct Answer is B

The nurse should contact the local Department of Health and Human Services for the client, as this agency may be able to provide assistance with heating costs or other resources for low-income individuals.

Older adults are at increased risk of hypothermia, which is a potentially life-threatening condition that occurs when body temperature drops below 35° C (95° F). Hypothermia can be caused by exposure to cold temperatures, inadequate clothing, poor nutrition, chronic illness, or medication use. Therefore, it is important for the nurse to intervene and help the client maintain a safe and comfortable home environment.

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Correct Answer is C

Explanation

B. This response educates the client about the importance of taking the prescribed medication and reinforces the authority and expertise of the provider. However, it does not respect the client's autonomy to make independent healthcare decisions

C.This response acknowledges that the client has reservations about the antibiotics and offers to communicate this to the healthcare provider for further intervention.

A. The amount of drainage is gradually decreasing. B. The client's abdomen becomes distended and firm. C. The client reports being extremely thirsty with a sore throat. D. The drainage is bright green in color with brown fecal material.

Correct Answer is B

Explanation

Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation.

The nurse should report this finding to the provider and assess for signs of shock or peritonitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity?

A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?

A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer?

A nurse is teaching a group of clients who have cancer about radiation therapy. Which of the following activities should the nurse include in the teaching?

A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?

A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?

A nurse is providing discharge teaching for a client who has HIV. Which of the following information is the priority for the nurse to review with the client?