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 D

Explanation

Valsartan is an angiotensin II receptor blocker that lowers blood pressure by blocking the vasoconstrictive and aldosterone-secreting effects of angiotensin II. Loweringblood pressure reduces the workload of the heart and improves cardiac function in patients with heart failure . Decreased urinary output, increased heart rate, and increased potassium level are not expected outcomes of valsartan therapy and may indicate worsening of heart failure or adverse effects of the medication.

A. Describe the sensations the client will feel during the procedure. B. Reinforce the importance of lying still during the procedure. C. Administer a sedative medication. D. Determine whether the client has an allergy to local anesthetics.

Correct Answer is D

Explanation

The priority intervention for the nurse is to determine whether the client has an allergy to local anesthetics, as this could cause a serious adverse reaction during the procedure.

Thoracentesis is a minimally invasive procedure that involves inserting a needle into the pleural space to drain excess fluid or air from around the lungs. The procedure requires local anesthesia to numb the area where the needle is inserted. Therefore, it is essential to assess for any allergy to local anesthetics before proceeding with the procedure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an indication that the medication is effective?

Correct Answer is D

Explanation

A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?

Correct Answer is D

Explanation

A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?

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 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 completing discharge teaching with a client who has a peripherally inserted central catheter (PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching?

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 reviewing the following ABG results for a postoperative client: pH 7.27, PaCO2 49 mm Hg, PaO2 65 mm Hg, HCO 22 mEq/L. The nurse should interpret the findings as which of the following imbalances?

A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following actions should the nurse take first?

A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permanent pacemaker?