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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Correct Answer is B

Explanation

A. "I will move your joints to the point of mild pain." - This statement is incorrect. Passive ROM exercises should not be performed to the point of causing pain. Pain during passive ROM exercises can indicate that the movement is too forceful or beyond the client's range of motion, which can lead to injury or discomfort.

B. "I will repeat these movements 3 to 5 times." - This statement is generally correct. Passive ROM exercises are typically repeated several times during each session to help maintain joint mobility and prevent contractures. The specific number of repetitions can vary based on the client's needs and tolerance.

C. "I will move your joints quickly." - This statement is incorrect. Passive ROM exercises should be performed slowly and gently to avoid causing discomfort or injury to the client. Slow movements allow for better control and precision, ensuring that the joints are moved through their full range of motion without undue force.

D. "These movements will be performed once per day." - This statement is incorrect. Passive ROM exercises are usually performed multiple times throughout the day, especially for clients with decreased mobility. Regular and frequent sessions help prevent stiffness, maintain flexibility, and promote circulation in the joints.

A. Apply the pouch while the skin barrier is still damp. B. Change the pouch once every 24 hr. C. Rub the peristomal skin dry after cleaning. D. Ensure the pouch is 0.32 cm (1/ in) larger than the stoma.

Correct Answer is D

Explanation

A. Apply the pouch while the skin barrier is still damp.

Applying the pouch while the skin barrier is damp can lead to poor adhesion and potential leaks. It’s essential to ensure the skin is completely dry before attaching the pouch.

B. Change the pouch once every 24 hr.: The frequency of pouch changes depends on individual client needs, stoma output, and the type of pouching system used. Changing the pouch every 24 hours may be unnecessary for some clients and could potentially cause skin irritation or damage.

C. Rub the peristomal skin dry after cleaning: Rubbing the peristomal skin dry after cleaning can cause irritation and damage to the skin. Instead, the nurse should gently pat the skin dry using a soft cloth or towel to avoid causing friction or trauma to the delicate skin surrounding the stoma.

D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma:a allows for a better fit and helps prevent the edges of the stoma from coming into contact with stool, which can cause irritation and breakdown of the skin. A proper fit also helps ensure a secure seal and prevents leakage.

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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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