A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Record information about the home visit according to agency policy.
Contact the family to determine availability and readiness to make an appointment.
Discuss plans for future visits with the family.
Clarify the reason for the referral with the provider's office.
Identify family needs and interventions using the nursing process.
The Correct Answer is D,B,E,C,A
Rationale:
A. Record information about the home visit according to agency policy: Documentation is performed at the end of the visit to ensure that all observations, interventions, and plans are accurately recorded in the client’s record for continuity of care.
B. Contact the family to determine availability and readiness to make an appointment: Before visiting, the nurse should coordinate with the family to schedule a convenient time, ensuring that they are prepared for the assessment and intervention process.
C. Discuss plans for future visits with the family: After assessing the client and identifying needs, the nurse should collaborate with the family to plan ongoing visits and care strategies that align with their goals and availability.
D. Clarify the reason for the referral with the provider's office: This is the first step to ensure the nurse understands the purpose of the referral, specific concerns, and any important background information before contacting the family.
E. Identify family needs and interventions using the nursing process: During the visit, the nurse collects data, assesses needs, and develops appropriate interventions, forming the foundation for the care plan moving forward.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.
B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.
C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.
D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.
Correct Answer is ["C","D","E","F"]
Explanation
Rationale:
A. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics used to treat postpartum endometritis are safe for breastfeeding. Temporary formula feeding is not routinely required.
B. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor, which is not indicated postpartum. It does not treat infection or uterine complications.
C. Monitor the height and tone of the client's fundus: Assessing the uterus for firmness and position helps detect uterine atony or worsening infection. Changes in fundal height or tone can indicate retained products of conception or hemorrhage.
D. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene reduces the risk of introducing or spreading bacteria to the uterus or perineal area, which is critical when postpartum infection is present.
E. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes drainage of lochia, decreases uterine congestion, and supports recovery from endometritis by reducing bacterial proliferation in pooled fluid.
F. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: A culture helps identify the causative organism of endometritis, allowing the provider to tailor antibiotic therapy effectively.
G. Initiate contact precautions: Endometritis is not a highly transmissible condition; standard precautions, including hand hygiene, are sufficient unless another communicable infection is identified.
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