A home health nurse is conducting a home-safety risk appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

Water heater temperature 54.4°C (130° F)

Electric cords behind furniture

Bathtub with rails

Raised toilet seats

Throw rugs

Answer and Explanation

Correct Answer : A,B,E

A. Water heater temperature 54.4°C (130° F):

This water heater temperature is too high and poses a scalding risk. The recommended temperature setting for water heaters is generally below 49°C (120° F) to prevent burns.

B. Electric cords behind furniture:

Placing electric cords behind furniture can create tripping hazards. It is safer to have cords organized and placed away from areas where the client may walk.

C. Bathtub with rails:

Having a bathtub with rails is a safety feature that can assist the client in getting in and out of the bathtub safely. It is not a safety risk.

D. Raised toilet seats:

Raised toilet seats are often recommended for older adults to facilitate safe and easier use of the toilet. They are not a safety risk when used appropriately.

E. Throw rugs:

Throw rugs can be a tripping hazard, especially for older adults who may have mobility issues. They should be secured or removed to prevent falls.

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Correct Answer is B

Explanation

A. Asking family members to leave the room might be necessary for privacy, but it depends on the situation and the client's preferences. However, it might not be the only action needed to maintain privacy during the bed bath.

B. Closing the curtains around the client's bed is an essential step to shield the client from the view of others in the room. It helps create a private space for the bed bath procedure.

C. Using a blanket to cover the client might provide some modesty, but it might not offer enough privacy during the bed bath, especially if the client requires a complete bath that involves exposure of different body parts.

D. Closing the door of the client's room can help maintain privacy if there are no other visitors or staff who might inadvertently enter. However, closing the curtains around the bed is more specific to creating a private area during the bed bath itself.

A. Request a dietary consult. B. Check the client's vital signs. C. Request an order for an antiemetic. D. Suggest that the client rests before eating the meal.

Correct Answer is B

Explanation

A. Request a dietary consult:

While dietary concerns may be addressed, checking vital signs is the priority when a client reports nausea, especially in the context of medication administration.

B. Check the client's vital signs:

This is the correct action. Nausea can be a symptom of digoxin toxicity. Checking vital signs, especially assessing for changes in heart rate, is crucial in determining whether the client is experiencing adverse effects of digoxin.

C. Request an order for an antiemetic:

Administering an antiemetic may be considered later, but the first priority is to assess the client's vital signs and determine if the nausea is related to digoxin toxicity.

D. Suggest that the client rests before eating the meal:

Resting before eating may be helpful for nausea, but the priority is to assess the client's vital signs and determine the cause of the nausea, especially in the context of digoxin use.

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A home health nurse is conducting a home-safety risk appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

Correct Answer is B

Explanation

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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