A nurse is caring for a female client, 84 years old, in the home environment. The client was recently hospitalized for an exacerbation of heart failure (HF) and moved in with her daughter after the hospitalization. Below is the information available to the nurse for interpretation:
Encourage the client to increase physical activity and engage with peers.
Suggest the client remain in bed to avoid unnecessary exertion.
Teach the caregiver how to monitor for signs of infection in pressure injuries.
Assist the client in using the restroom to avoid incontinence.
Correct Answer : A,C,D
The correct answers are Choices A, C, and D.
Choice A rationale: Encouraging the client to increase physical activity and engage with peers is appropriate as it helps prevent deconditioning, improves cardiovascular health, and promotes mental well-being. Physical activity can also improve muscle strength, mobility, and overall quality of life.
Choice B rationale: Suggesting the client remain in bed to avoid unnecessary exertion is incorrect. Prolonged bed rest can lead to muscle atrophy, pressure injuries, and decreased cardiovascular function. The client should be encouraged to mobilize as tolerated to maintain functional abilities.
Choice C rationale: Teaching the caregiver how to monitor for signs of infection in pressure injuries is crucial because the client has stage II pressure injuries that need careful monitoring and management to prevent complications such as infection. Education on signs of infection, proper wound care, and prevention strategies is essential.
Choice D rationale: Assisting the client in using the restroom to avoid incontinence is appropriate as it respects the client's preference for toileting, reduces the risk of skin breakdown, and promotes dignity. Helping the client maintain continence and proper hygiene is important for comfort and overall health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Lathering using a circular movement is an effective handwashing technique. This method ensures thorough coverage of all surfaces of the hands, including areas that are often missed, such as between the fingers and under the nails. The friction generated by the circular motions helps dislodge dirt, bacteria, and viruses from the skin. Proper lathering is a crucial step in reducing the microbial load on the hands and preventing the spread of infections.
Choice B rationale
Turning the water off using bare hands contaminates the hands after they have been washed. This action can reintroduce bacteria or viruses from the faucet handle back onto the clean hands, negating the benefits of handwashing. Proper hand hygiene protocol recommends using a paper towel or elbow to turn off the water to maintain the cleanliness achieved by washing. This step is critical in breaking the chain of infection transmission.
Choice C rationale
Washing hands for a total of 20 seconds is in line with the recommended guidelines from health organizations like the CDC. This duration is considered sufficient to effectively remove soil, dirt, and transient microorganisms from the skin. It allows enough time for the soap to act on contaminants and for mechanical action to dislodge them. Adhering to this time frame is an essential component of effective hand hygiene practices.
Choice D rationale
Holding hands below the elbows when rinsing ensures that water flows from the wrists down to the fingertips, effectively washing away soap and contaminants. This technique prevents recontamination of the hands by keeping the direction of water flow from the cleanest to the dirtiest areas. Proper rinsing is a key aspect of hand hygiene, ensuring that all soap residues, along with any remaining microorganisms, are thoroughly removed.
Correct Answer is A
Explanation
Choice A rationale
Withholding the dose is the safest action to avoid potential overdose or toxicity. Digoxin has a narrow therapeutic window, and administering an additional dose without knowing how much was absorbed could lead to dangerous side effects.
Choice B rationale
Administering a half dose now is not recommended because it is unclear how much of the original dose was absorbed. This could result in either an insufficient dose or an overdose, leading to ineffective treatment or potential toxicity.
Choice C rationale
Giving another dose is not safe because there is a risk of overdosing the infant. Digoxin toxicity can cause serious complications, and it is crucial to avoid administering more medication until the next scheduled dose.
Choice D rationale
Mixing the next dose with food is not appropriate because it does not address the immediate concern of potential overdose. The priority is to withhold the dose and monitor the infant's condition.
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