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 : A,C,D

The correct answer is Choice A, Choice C, and Choice D.

Choice A rationale: A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.

Choice B rationale: Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.

Choice C rationale: Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.

Choice D rationale: Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.

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Correct Answer is A

Explanation

Choice A reason: The presence of soft, formed, and light brown feces is normal and does not preclude testing for occult blood. The nurse should proceed with obtaining the specimen as ordered.
Choice B reason: There is no need to contact the healthcare provider before obtaining the specimen if the stool appears normal and the test for occult blood has been ordered.
Choice C reason: Waiting for observable blood is not necessary for an occult blood test, which is designed to detect blood that is not visible to the naked eye.
Choice D reason: Withholding specimen collection until tarry black stool is observed is not indicated. Tarry black stool can indicate bleeding in the upper gastrointestinal tract, but the test for occult blood is used to detect blood that may not be visible in the stool. Bolded text indicates the correct answers and important information.

A. Leave the dressing off until consulting with the healthcare provider. B. Replace the gauze with a transparent dressing. C. Increase the frequency of the dressing changes. D. Apply a hydrocolloid gel dressing.

Correct Answer is D

Explanation

Choice A reason: Leaving the dressing off is not advisable as it can expose the wound to potential infection and delay healing.

Choice B reason: A transparent dressing may not be the best choice for a stage 3 pressure injury with significant granulation tissue.

Choice C reason: Increasing the frequency of dressing changes without specific orders may not be necessary and could disrupt the healing process.

Choice D reason: A hydrocolloid gel dressing is appropriate for a stage 3 pressure injury as it maintains a moist environment, which is conducive to wound healing and granulation.

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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

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is D

Explanation

A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

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?

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

Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.