A home health nurse is teaching a client who has a latex allergy about items typically found in the home that can trigger an allergic reaction. Which of the following items should the nurse instruct the client to avoid? (Select all that apply.).

Dishwashing gloves.

Adhesive tape.

Macadamia nuts.

Bananas.

Rubber bands.

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale:

Dishwashing gloves are often made of latex, which can trigger an allergic reaction in individuals with a latex allergy. Direct contact with latex-containing items should be avoided to prevent allergic responses.

Choice B rationale:

Adhesive tape commonly contains latex and can lead to allergic reactions in individuals with a latex allergy. Avoiding contact with latex-containing items is crucial to prevent potential allergic symptoms.

Choice C rationale:

Macadamia nuts and bananas do not typically contain latex and are not known to trigger latex allergies. While these items can cause allergic reactions in some individuals, they are not relevant to a latex allergy.

Choice D rationale:

While macadamia nuts and bananas can cause allergies in some people, they do not contain latex and are not associated with latex allergies. Therefore, they are not items that the nurse needs to instruct the client to avoid due to their latex allergy.

Choice E rationale:

Rubber bands are often made from latex, which can provoke an allergic reaction in individuals with a latex allergy. Encouraging the client to steer clear of items like rubber bands helps prevent potential allergic responses.

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Correct Answer is B

Explanation

Choice A rationale:

Increased sensitivity to touch is not an expected physiological change associated with aging. Older adults often experience decreased sensitivity to touch due to changes in nerve endings and decreased skin elasticity. This can lead to decreased sensation rather than increased sensitivity.

Choice B rationale:

Decreased peripheral circulation is an expected physiological change associated with aging. With age, blood vessels can become less elastic and more narrow, leading to reduced blood flow to the extremities. This can result in cold extremities, delayed wound healing, and increased vulnerability to skin breakdown. Nurses should assess for signs of impaired circulation in older adult clients and provide appropriate interventions to prevent complications.

Choice C rationale:

Decreased airway resistance is not an expected physiological change associated with aging. Older adults often experience increased airway resistance due to changes in lung elasticity and chest wall compliance. This can lead to decreased lung function and a higher risk of respiratory issues such as pneumonia and bronchitis.

Choice D rationale:

Increased appetite is not an expected physiological change associated with aging. In fact, many older adults experience a decrease in appetite due to factors such as changes in metabolism, decreased sense of taste and smell, and underlying health conditions. This reduced appetite can contribute to malnutrition and weight loss in the elderly population.

A. Slowly instill 400 to 500 mL of the prescribed solution. B. Clamp the drainage tubing distal to the injection port. C. Use a syringe with a 19-gauge needle. D. Withdraw the irrigation solution into the syringe.

Correct Answer is A

Explanation

Choice A rationale:

During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.

Choice B rationale:

Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.

Choice C rationale:

Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.

Choice D rationale:

Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.

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A home health nurse is teaching a client who has a latex allergy about items typically found in the home that can trigger an allergic reaction. Which of the following items should the nurse instruct the client to avoid? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an older adult client. Which of the following should the nurse identify as an expected physiological change associated with aging?

Correct Answer is B

Explanation

A nurse is performing a bladder irrigation for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is setting up a sterile field prior to changing a client's dressing. Which of the following actions should the nurse take?

A nurse is caring for a client who reports using alcohol and controlled substances to cope with the death of their partner. The nurse should identify that maladaptive coping is an indication of which of the following types of complicated grief?

A home health nurse is teaching a client who has a latex allergy about items typically found in the home that can trigger an allergic reaction. Which of the following items should the nurse instruct the client to avoid? (Select all that apply.).

A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose?

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

A nurse is leaving a client's isolation room. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?