A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?

"I will weigh myself once weekly."

"I will take my new medication in the evening."

"I will take a hot bath before going to bed."

"I will leave a light on in my bathroom at night."

Answer and Explanation

The Correct Answer is D

A. "I will weigh myself once weekly." Clients with heart failure should weigh themselves daily to monitor for fluid retention. A sudden weight gain (e.g., 2-3 lbs in 24 hours or 5 lbs in a week) may indicate worsening heart failure and should be reported to the provider.

B. "I will take my new medication in the evening." Hydrochlorothiazide is a diuretic that increases urine output. Taking it in the evening can lead to nocturia and sleep disturbances. Instead, it should be taken in the morning to minimize nighttime urination.

C. "I will take a hot bath before going to bed." Hot baths can cause vasodilation, leading to a drop in blood pressure (orthostatic hypotension), which increases the risk of dizziness and falls, especially in older adults taking diuretics. A warm (not hot) bath is safer.

D. "I will leave a light on in my bathroom at night." Older adults, especially those taking diuretics like hydrochlorothiazide, are at increased risk for nocturia and falls due to frequent trips to the bathroom. Keeping a light on in the bathroom at night enhances visibility and reduces the risk of falls, which is a major concern in this population.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A.Place the sterile field at the level of the nurse’s hips: This is not a recommended action. The sterile field should be placed at waist level or slightly above to ensure easy access and prevent contamination.

B. Hold bottles of sterile solution with the label in the palm of the hand: This protects the label from becoming wet and illegible, which is proper sterile technique.

C. Open the outermost flap of the sterile kit toward the body: When opening a sterile kit or package, the nurse should open the outermost flap away from the body to prevent contamination. Opening the flap toward the body increases the risk of airborne particles or contaminants from the nurse's clothing or skin entering the sterile field.

D. Sterile liquids should be poured into sterile containers on the sterile field, taking care not to contaminate the field.

A. "Tell me more about your partner." B. "Have you thought about harming yourself?" C. "You should discuss these feelings with your provider." D. "Why did you stop taking your medication?"

Correct Answer is B

Explanation

A. "Tell me more about your partner." - While exploring the client's feelings about their partner may be relevant to understanding their current emotional state, it does not directly address the statement indicating suicidal ideation. The priority in this situation is to assess the client's risk of self-harm or suicide.

B. "Have you thought about harming yourself?"

This response directly addresses the client's statement expressing thoughts of dying and allows the nurse to assess the client's risk of self-harm or suicide. It opens up a dialogue about the client's feelings and intentions, which is crucial for ensuring their safety and providing appropriate support and intervention.

C. "You should discuss these feelings with your provider." - While encouraging the client to communicate with their healthcare provider is important, it does not address the immediate concern of potential self-harm or suicide. The nurse should assess the client's safety and provide support before encouraging further discussion with the provider.

D. "Why did you stop taking your medication?" - While medication non-adherence may contribute to worsening symptoms of depression, it is not the immediate concern in this situation. The client's statement expressing thoughts of dying requires immediate assessment of suicidal ideation and intervention to ensure their safety.

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A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?

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A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?

Correct Answer is B

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