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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Ensure that the client's bed is in the lowest position.
Keeping the bed in the lowest position helps prevent injury if the client tries to get out of bed, especially when restrained.
B. Assess skin temperature and color before applying the restraints.
This action ensures proper circulation and skin integrity while the restraints are in use. It helps prevent skin breakdown and injury.
C. Attach the client's restraints to the bed rail.
Attaching restraints to the bed rail is not considered a best practice as it can increase the risk of injury to the client. Restraints should be secured to the bed frame or another stable part of the bed to minimize the risk of harm.
D. Pad bony prominences before applying the restraints.
Padding bony prominences such as elbows and wrists helps prevent pressure ulcers and discomfort caused by the restraints.
E. Secure restraints to allow three fingers to slide under the restraints.
Restraints should be secured to allow only two fingers to slide under the restraints to ensure they are not too loose or too tight.
Correct Answer is B
Explanation
A. Eyewear: Eyewear, such as goggles or a face shield, should be removed after the mask. Eyewear protects the eyes from exposure to infectious respiratory droplets or aerosols. When removing eyewear, the nurse should handle it by the sides and avoid touching the front surface, which may be contaminated.
B. Gloves: Gloves are the first item to be removed when leaving the client's room. This is because gloves are in direct contact with potentially contaminated surfaces or materials. Removing gloves first helps prevent the spread of pathogens from the gloves to other parts of the PPE or the nurse's skin.
C. Mask: After removing gloves, the nurse should remove the mask next. Masks are worn to protect the respiratory system from inhaling airborne infectious particles. When removing the mask, it's important to handle it by the straps or ties and avoid touching the front surface, which may have been exposed to pathogens.
D. Gown: The gown is the last item to be removed. Gowns provide coverage to protect clothing and skin from contamination. When removing the gown, it's important to do so carefully to avoid contaminating oneself or the surrounding environment.
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