An older adult client with unintentional weight loss and a decline in physical health reports to the nurse of skipping meals to save money for prescribed medications. Which action is best for the home health nurse to implement?

Provide budgeting strategies.

Consult with social services.

Call the client's nearest relative.

Alert the adult protection agency.

Answer and Explanation

The Correct Answer is B

A.   Provide budgeting strategies. While this can be helpful, it does not address the immediate need for resources and assistance with both medications and food.
B.   Consult with social services. Social services can help the client access resources such as food assistance programs, medication assistance programs, and other community resources to ensure the client’s nutritional and medical needs are met.
C.   Call the client's nearest relative. This might provide some immediate support, but it is not a comprehensive solution. The relative may not be able to provide the needed resources or may not be in a position to help effectively.
D.   Alert the adult protection agency. While this step might be necessary if there is evidence of neglect or abuse, it is not the most appropriate first action in a situation where the client needs assistance with resources.

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Correct Answer is B

Explanation

A. Determine pH value of specimen. While pH testing can help confirm gastric placement of the NGT, the appearance of cloudy green fluid suggests a different issue that should be addressed first.
B. Send fluid specimen to the laboratory. Cloudy green fluid aspirated from the NGT suggests possible infection or contamination and should be sent to the laboratory for analysis to determine the presence of pathogens or other abnormalities.
C. Withdraw the NGT and reinsert. This may be necessary if placement is incorrect, but the cloudy green fluid suggests a potential issue beyond placement.
D. Connect the NGT to wall suction. Suctioning should not be initiated until the nature of the aspirated fluid is determined. If the fluid is infected, suctioning it could spread pathogens or cause further complications.

A. Scrambled eggs with roasted peppers and onions, lean ham, and toast. B. Poached egg, bacon, biscuit and canned peaches in light syrup. C. Oatmeal with raisins and nuts, with skim milk and 1/2 grapefruit. D. Pancakes with blueberries and maple syrup, and a turkey sausage patty. E. Pancakes with blueberries and maple syrup, and a turkey sausage patty.

Correct Answer is C

Explanation

A. Scrambled eggs with roasted peppers and onions, lean ham, and toast. This meal contains lean protein from the eggs and ham, which is beneficial, but it lacks significant amounts of cancer- fighting nutrients found in fruits, vegetables, and whole grains.
B. Poached egg, bacon, biscuit, and canned peaches in light syrup. Bacon and canned peaches in syrup are not recommended for cancer prevention due to their high content of saturated fats and added sugars, respectively.
C. Oatmeal with raisins and nuts, with skim milk and 1/2 grapefruit. This meal contains whole grains from the oatmeal, antioxidants from the raisins and nuts, and vitamin C from the grapefruit, all of which have been associated with reducing the risk of certain cancers.
D. Pancakes with blueberries and maple syrup, and a turkey sausage patty. While blueberries are rich in antioxidants, the pancakes and maple syrup contribute refined carbohydrates and added sugars, which are not recommended for cancer prevention.

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An older adult client with unintentional weight loss and a decline in physical health reports to the nurse of skipping meals to save money for prescribed medications. Which action is best for the home health nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse is conducting a nutritional class on foods that have been linked to help decrease the development of some forms of cancer. Which meal selection is the best choice to help reduce the risk of some cancers?

Correct Answer is C

Explanation

A client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider prescribes a low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions?

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When entering a client's room, the nurse observes that the unlicensed assistive personnel (UAP) has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse?

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