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. Hyperglycemia B. Hypoglycemia C. Diarrhea D. Hypertension

Correct Answer is B

Explanation

TPN is a form of intravenous nutrition that provides glucose, amino acids, lipids, vitamins, minerals, and electrolytes to clients who cannot eat or absorb nutrients through their gastrointestinal tract. Discontinuing TPN abruptly can cause a sudden drop in blood glucose levels, leading to hypoglycemia .

Hyperglycemia can occur during TPN administration if the glucose infusion rate is too high or if the client has insulin resistance . Diarrhea can occur as a result of infection, bowel ischemia, or intolerance to enteral feeding . Hypertension can occur due to fluid overload, electrolyte imbalance, or vascular complications .

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Nursing Test Bank

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 preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects?

Correct Answer is B

Explanation

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 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 who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

A nurse in a provider's office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

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?