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During a home visit, the nurse observes an elderly patient trying to walk to the bathroom. The patient appears unstable and clings to furniture while refusing any help.
What action should the nurse take?

Suggest that the patient get a walker.

Encourage the patient to acquire a medical alert device.

Ensure the patient’s privacy while in the bathroom.

Identify potential safety hazards in the home.

Answer and Explanation

The Correct Answer is D

Answer and explanation

The correct answer is Choice D.

Choice A rationale

While suggesting that the patient get a walker might help with mobility, it does not directly address the safety concerns in the home environment.

Choice B rationale

A medical alert device could be beneficial in case of emergencies, but it does not prevent the risk of falls or accidents in the home.

Choice C rationale

Ensuring the patient’s privacy is important, but it does not address the immediate safety concerns observed by the nurse.

Choice D rationale

Identifying potential safety hazards in the home is the most immediate and effective action the nurse can take. By doing this, the nurse can work with the patient and their family to make necessary changes to improve safety and prevent falls.

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Correct Answer is B

Explanation

Answer and explanation

The correct answer is Choice B.

Choice A rationale

A potassium level of 3.7 mEq/L (3.7 mmol/L) is within the normal range, which is typically between 3.6 and 5 mEq/L12. Therefore, this result does not need to be reported immediately to the healthcare provider.

Choice B rationale

B-type natriuretic peptide (BNP) levels are used to diagnose and monitor heart failure. A BNP level of 550 pg/mL (550 ng/L) is significantly higher than the normal range, which is less than 100 pg/mL34. High BNP levels indicate that the heart is working harder than normal, which is a common occurrence in heart failure. Therefore, this result should be reported immediately to the healthcare provider.

Choice C rationale

A total cholesterol level of 190 mg/dL (4.92 mmol/L) is considered borderline high. While it’s important to manage cholesterol levels in patients with heart failure, this result is not critical and does not need to be reported immediately to the healthcare provider.

Choice D rationale

A glycosylated hemoglobin (A1C) level of 7% is at the threshold for the diagnosis of diabetes. Diabetes can complicate the management of heart failure and increase the risk of cardiovascular events. However, this result is not critical and does not need to be reported immediately to the healthcare provider.

A. Recheck the client’s vital signs in 30 minutes. B. Have the client transported via ambulance to the hospital. C. Determine the client’s current oxygen saturation rate. D. Instruct the client to drive to the hospital for admission.

Correct Answer is B

Explanation

Answer and explanation

The correct answer is Choice B.

Choice A rationale

Rechecking the client’s vital signs in 30 minutes may not be the most appropriate action in this situation. The client is showing signs of possible complications such as infection (elevated

temperature, malaise) and referred pain in the shoulder, which could indicate diaphragmatic irritation. These symptoms, along with the client’s recent surgery, suggest that immediate medical attention may be necessary.

Choice B rationale

Having the client transported via ambulance to the hospital is the most appropriate action. The client’s symptoms suggest possible complications that require immediate medical attention.

Abdominal tenderness and shoulder pain could indicate a serious condition such as a perforation or infection. The elevated heart rate and low blood pressure could suggest sepsis or shock. Immediate medical evaluation and treatment are necessary.

Choice C rationale

Determining the client’s current oxygen saturation rate is important, but it is not the most immediate need. While this information could provide additional data about the client’s condition, it does not address the potential seriousness of the client’s symptoms. The client needs immediate medical attention.

Choice D rationale

Instructing the client to drive to the hospital for admission is not the best choice. Given the client’s symptoms and recent surgery, it would be safer for the client to be transported by ambulance. This would ensure that the client receives immediate medical attention and that the client’s condition can be monitored during transport.

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During a home visit, the nurse observes an elderly patient trying to walk to the bathroom. The patient appears unstable and clings to furniture while refusing any help.What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is examining the lab results of several patients with a history of heart failure (HF). Which patient’s finding should the nurse immediately report to the healthcare provider?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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During a home visit, the nurse observes an elderly patient trying to walk to the bathroom. The patient appears unstable and clings to furniture while refusing any help.
What action should the nurse take?