A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?
"I will weigh myself once weekly."
"I will take my new medication in the evening."
"I will take a hot bath before going to bed."
"I will leave a light on in my bathroom at night."
The Correct Answer is D
A. "I will weigh myself once weekly." Clients with heart failure should weigh themselves daily to monitor for fluid retention. A sudden weight gain (e.g., 2-3 lbs in 24 hours or 5 lbs in a week) may indicate worsening heart failure and should be reported to the provider.
B. "I will take my new medication in the evening." Hydrochlorothiazide is a diuretic that increases urine output. Taking it in the evening can lead to nocturia and sleep disturbances. Instead, it should be taken in the morning to minimize nighttime urination.
C. "I will take a hot bath before going to bed." Hot baths can cause vasodilation, leading to a drop in blood pressure (orthostatic hypotension), which increases the risk of dizziness and falls, especially in older adults taking diuretics. A warm (not hot) bath is safer.
D. "I will leave a light on in my bathroom at night." Older adults, especially those taking diuretics like hydrochlorothiazide, are at increased risk for nocturia and falls due to frequent trips to the bathroom. Keeping a light on in the bathroom at night enhances visibility and reduces the risk of falls, which is a major concern in this population.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Grab bars are installed in the shower: Installing grab bars in the shower is a safety measure that helps prevent falls and assists the client in safely maneuvering in the bathroom. This finding indicates a safe environment and does not require intervention.
B. The hot water heater is set to 47°C (117°F): The hot water heater set at 47°C (117°F) poses a scalding risk, especially for older adults with decreased sensation or mobility issues. The recommended safe temperature for hot water heaters is typically below 49°C (120°F) to prevent burns. Therefore, the nurse should intervene to adjust the temperature to a safer level.
C. There is an area rug covering a tile floor.
Area rugs covering tile floors can pose a significant fall risk, especially for older adults with osteoporosis, who are more susceptible to fractures. The rug can slip or bunch up, leading to trips and falls. Therefore, the nurse should intervene to remove the area rug or secure it firmly to the floor to prevent accidents.
D. Prescriptions are stored in a medication organizer: Storing prescriptions in a medication organizer promotes medication adherence and organization, which is beneficial for older adults managing multiple medications. This finding indicates good medication management and does not require intervention.
Correct Answer is A
Explanation
A. Client care provider
In this scenario, the nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client to ensure client safety. By directly overseeing the procedure and providing guidance, feedback, and support, the nurse manager is assuming the role of a client care provider. This role involves ensuring that nursing care is delivered effectively and safely, especially when orienting or supervising new staff members.
B. Client educator:
While client education is important in nursing practice, the nurse manager's primary role in this scenario is not to educate the client but rather to observe and supervise the newly licensed nurse performing a procedure.
C. Client advocate:
Although advocating for client safety is a fundamental aspect of nursing practice, in this specific scenario, the nurse manager is more directly involved in overseeing the procedural skill of the newly licensed nurse rather than advocating for the client's rights or needs.
D. Case manager:
A case manager typically coordinates and manages the overall care of clients, including planning and arranging services. However, in this scenario, the nurse manager's role is focused on directly observing and supervising a specific nursing procedure rather than coordinating broader aspects of the client's care.
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