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

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

A. Insert a saline lock into a site 10 cm (4 in) distal to the graft. B. Instruct the client to avoid lifting the right arm for 72 hr. C. Palpate the site for a thrill. D. Check blood pressure in the right arm.

Correct Answer is C

Explanation

Palpating the site for a thrill is an important action to assess the patency and function of an arteriovenous graft, which is a synthetic tube that connects an artery and a vein for hemodialysis access. A thrill is a vibration felt over the graft that indicates blood flow. The other options are incorrect because they could compromise or damage the graft.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has increased intracranial pressure (ICP). The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances?

A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?

A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take?

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?

A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make?

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 reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?