A home health nurse is planning care for a client who has Alzheimer's disease.
Which of the following actions should the nurse include in the plan of care?

Wear clothing with zippers instead of buttons.

Place locks at the tops of exterior doors.

Replace the carpet with hardwood floors.

Encourage physical activity prior to bedtime.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Wearing clothing with zippers instead of buttons does not address the safety concerns related to Alzheimer's disease. This choice does not ensure the client's safety or prevent wandering, which are common issues in Alzheimer's patients.

Choice B rationale:

Placing locks at the tops of exterior doors is essential for the safety of clients with Alzheimer's disease. Alzheimer's patients often have a tendency to wander and may become disoriented, putting them at risk of getting lost or injured outside the home. Proper locks can prevent them from leaving the house unsupervised.

Choice C rationale:

Replacing the carpet with hardwood floors may reduce the risk of falls but does not specifically address the safety concerns related to Alzheimer's disease. It is important to focus on measures that prevent wandering and ensure the client's safety in various situations.

Choice D rationale:

Encouraging physical activity prior to bedtime is a good practice for promoting sleep in older adults but does not directly address the safety concerns of Alzheimer's patients. Safety measures, such as securing doors, supervising the client, and preventing wandering, are more crucial in this context.

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Correct Answer is C

Explanation

The correct answer is Choice C, the system is working properly.

Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure.Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained

Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection.The tubing should be straight and free of kinks or loops

Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space.Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped

Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress.The tubing should be checked regularly for clots and milked gently if needed

A. "The estimated blood loss was 250 milliliters." B. "The client was intubated without complications." C. "The client is a member of the board of directors." D. "There was a total of 10 sponges used during the procedure." .

Correct Answer is A

Explanation

Answer is: a. "The estimated blood loss was 250 milliliters."

Explanation: Including the estimated blood loss during the procedure in the hand-off report is relevant information that impacts the patient's care and helps the receiving nurse assess the patient's condition and monitor for complications.

Choice b. is wrong because the client has been transferred to the PACU, it is implied that the intubation has been removed. The focus should be on the patient's current condition and any potential complications related to the procedure.

Choice c. is wrong because the client's role as a member of the board of directors does not directly affect their medical care. Nurses should maintain patient confidentiality and only discuss relevant information regarding the patient's health status.

Choice d. is wrong because the number of sponges used during the procedure is not essential information to include in the hand-off report. The focus should be on the patient's current condition and any potential complications.

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A home health nurse is planning care for a client who has Alzheimer's disease.Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling?

Correct Answer is C

Explanation

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Correct Answer is A

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A home health nurse is planning care for a client who has Alzheimer's disease.
Which of the following actions should the nurse include in the plan of care?