The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Shufling gait.

Urinary incontinence.

Syncope when bending.

Hand tremors.

Answer and Explanation

Correct Answer : C,D

Choice A rationale: A shuffling gait increases fall risk but does not directly impair ability to perform foot care or toenail trimming, so UAP assignment is not primarily indicated here.

Choice B rationale: Urinary incontinence affects bladder control, not manual dexterity or safety during foot care. It does not necessitate UAP assistance for toenail trimming or routine foot care.

Choice C rationale: Syncope when bending increases risk of fainting during foot care tasks, making independent toenail trimming unsafe. UAP support ensures safety and prevents injury during routine care.

Choice D rationale: Hand tremors impair fine motor control, making toenail trimming difficult and unsafe. UAP assistance is indicated to prevent injury and ensure proper routine foot care.

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Correct Answer is B

Explanation

Choice A reason: Slip-on rubber shower shoes are not recommended as they do not provide the necessary support or stability for a client with weakness on one side.

Choice B reason: Tennis shoes with Velcro are ideal as they offer good support and are easy to fasten, which is beneficial for a client with one-sided weakness and potentially limited dexterity.

Choice C reason: Leather-soled loafers can be slippery and do not offer the snug fit and support needed for safe ambulation post-stroke.

Choice D reason: Rubber-soled slippers may provide some grip but typically do not offer the structured support that is necessary for a client with post-stroke weakness.

A. Increase the liter flow of oxygen. B. Encourage the client to take deep breaths. C. Remove the mask to deflate the bag. D. Document the assessment data.

Correct Answer is A

Explanation

Choice A reason: If the oxygen reservoir bag of a partial rebreather mask does not deflate completely during inspiration, it may indicate that the flow rate is too low. Increasing the liter flow ensures adequate delivery of oxygen.

Choice B reason: Encouraging the client to take deep breaths is beneficial for overall respiratory function but will not address the issue of the reservoir bag not deflating properly.

Choice C reason: Removing the mask to deflate the bag is not a standard practice and could interrupt the delivery of oxygen to the client.

Choice D reason: Documentation of the assessment data is important, but the nurse must first address the issue with the oxygen delivery system to ensure the client is receiving the proper amount of oxygen.

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The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Correct Answer is B

Explanation

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?

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