A home health nurse is conducting an initial environmental evaluation for an older adult client. Which of the following recommendations should the nurse make?

Set the hot water heater to 54.4° C (130° F).

Place a throw rug on the kitchen floor.

Remove the raised seat from the toilet.

Install a grab bar on the wall next to the toilet.

Answer and Explanation

The Correct Answer is D

A. Set the hot water heater to 54.4° C (130° F): This temperature is too high and poses a serious burn risk, especially for older adults with decreased skin sensitivity or delayed reaction times. The recommended safe setting is 48.9° C (120° F) or lower to prevent scalding injuries.

B. Place a throw rug on the kitchen floor: Throw rugs are a major tripping hazard for older adults and significantly increase the risk of falls. The nurse should recommend removing loose rugs or securing them with non-slip backing if they are necessary.

C. Remove the raised seat from the toilet: A raised toilet seat helps older adults with limited mobility or joint pain to sit and stand more easily, reducing the risk of falls or strain. Removing it would make toileting more difficult and unsafe.

D. Install a grab bar on the wall next to the toilet: Grab bars improve stability and reduce fall risk in key areas like the bathroom. They are a recommended safety measure for older adults, especially during toileting and bathing activities.

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Correct Answer is A

Explanation

A. "Your child may receive that immunization at 12 months." The MMR vaccine is recommended at 12 to 15 months of age, regardless of prematurity, as long as the child is healthy. By that time, the immune system is mature enough to respond effectively to the live attenuated vaccine.

B. "Your child will need to wait until he is older than 18 months since he was born early." Prematurity does not delay the MMR vaccination beyond the standard schedule. Delaying until after 18 months is unnecessary unless the infant has specific health concerns.

C. "Your child may receive that immunization at today's visit." At 6 months, the infant is too young for the routine MMR vaccine. While early administration may be considered in outbreak settings, it does not replace the routine first dose recommended at 12 months.

D. "Your child received that immunization when he was in the hospital." The MMR vaccine is not given in the neonatal period or during NICU stays. Live vaccines like MMR are delayed until the child is at least 12 months old and immunologically ready.

A. Encourage the client to talk B. Notify the rapid response team. C. Assist client to high-Fowler's position. D. Place emergency tracheostomy equipment in the client's room

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Potential Nursing Action	Anticipated	Contraindicated
Encourage the client to talk.		✔
Notify the rapid response team.	✔
Assist client to high-Fowler's position.	✔
Place emergency tracheostomy equipment in the client's room.	✔

Rationale:

Encourage the client to talk: Talking can strain the airway and worsen laryngeal edema or stridor. Airway obstruction is developing, and preserving respiratory function is critical. Silence reduces laryngeal movement and decreases airway irritation.
Notify the rapid response team: The client is showing signs of acute airway compromise: stridor, dysphagia, increasing temperature, and tachycardia. Immediate medical intervention is required to maintain oxygenation and prevent respiratory failure.
Assist client to high-Fowler's position: Sitting the client upright improves lung expansion and reduces pressure on the neck. This position facilitates breathing and airway patency, especially important during potential obstruction or edema.
Place emergency tracheostomy equipment in the client's room: Due to the risk of airway obstruction from laryngeal edema post-thyroidectomy, emergency airway access may be needed. Having tracheostomy equipment ready ensures rapid response if intubation becomes impossible.

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A home health nurse is conducting an initial environmental evaluation for an older adult client. Which of the following recommendations should the nurse make?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

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