A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)
"I need to check my medications for expiration dates."
"I need to have a fire escape plan with my family."
“1 need to set my hot water heater to 140 degrees Fahrenheit."
“1 will apply tape over frayed areas of electrical cords."
“1 will use the grab bars when getting in and out of the bathtub."
Correct Answer : A,B,E
Choice A reason:
Checking medication expiration dates is important to ensure that medications are safe and effective.
Choice B reason:
Having a fire escape plan is crucial in case of emergencies such as fires. It's important for the client and their family to know how to evacuate the home safely.
Choice C reason:
Setting the hot water heater to 140 degrees Fahrenheit is too hot and can lead to scalding. The recommended temperature is typically around 120 degrees Fahrenheit to prevent burns.
Choice D reason:
Applying tape to frayed electrical cords is not a safe practice. Frayed cords should be replaced to avoid electrical hazards.
Choice E reason:
Using grab bars when getting in and out of the bathtub can prevent slips and falls, especially in a potentially slippery environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B, C, E, D, A
Explanation
B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.
C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.
E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.
D.Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort
Correct Answer is C
Explanation
Choice A reason:
A blood glucose level of 110 mg/dl: A slightly elevated blood glucose level could be expected in response to enteral feeding.
Choice B reason:
Diarrhea one time in a 24-hour period is incorrect. Diarrhea can occur as a side effect of enteral feeding due to changes in the digestive process.
Choice C reason:
An unexpected finding when a client is receiving continuous enteral feeding via an NG tube is a rapid and significant weight gain of 0.91 kg (2 lb) in just 2 days. This could indicate fluid overload, which might be caused by excessive fluid intake or inadequate fluid removal by the body. Rapid weight gain should be assessed and reported as it could be a sign of underlying issues that need to be addressed.
Choice D reason:
A gastric residual of 300 mL at the end of the shift is incorrect. Gastric residuals can fluctuate during continuous enteral feeding, and a residual of 300 mL may not necessarily be unexpected depending on the client's overall condition and the healthcare provider's guidelines.
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