A nurse is inspecting equipment safety in a client's home. The nurse should identify that which of the following findings requires an intervention?
A fire extinguisher is kept in the kitchen.
An electrical ground plug is present.
The client's oxygen tanks are stored on their side.
The client's walking cane has a rubber tip.
The Correct Answer is C
A. A fire extinguisher is kept in the kitchen This is a safe and recommended practice, as the kitchen is a common area where fires may occur.
B. An electrical ground plug is present Ground plugs help prevent electrical shock and ensure safety, so no intervention is needed.
C. The client's oxygen tanks are stored on their side Oxygen tanks should always be stored upright and secured to prevent leaks or potential combustion. Storing them on their side increases the risk of damage to the tank or regulator, which can be hazardous.
D. The client's walking cane has a rubber tip A rubber tip provides stability and prevents slipping, making it a safe practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive.
Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required.
Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider.
Other Findings:
Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose.
Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients.
Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.
Correct Answer is B
Explanation
A. Chronic grief Chronic grief is prolonged and intense, lasting for an extended period without resolution. The client's symptoms suggest a different grief response.
B. Masked grief Masked grief occurs when a person experiences physical symptoms or maladaptive behaviors that they may not initially recognize as being related to their loss. The client's headaches, indigestion, and heart palpitations are physical manifestations of their grief.
C. Exaggerated grief Exaggerated grief involves intense emotions and self-destructive behaviors, such as depression, substance abuse, or suicidal thoughts, rather than primarily physical symptoms.
D. Delayed grief Delayed grief occurs when a person suppresses their emotions and does not experience grief reactions until later, often triggered by another event. The client's current physical symptoms suggest an ongoing response rather than a delayed one.
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