The home health aide caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
Listen for the presence of bowel sounds.
Administer a prescribed dose of a laxative.
Teach the client about foods high in fiber.
Assist the client to drink warm prune juice.
The Correct Answer is D
Choice A reason: Listening for the presence of bowel sounds is not a task that the home health aide can perform. This is a nursing assessment that requires specialized skills and equipment.
Choice B reason: Administering a prescribed dose of a laxative is not a task that the home health aide can perform. This is a nursing intervention that requires medication administration knowledge and authority.
Choice C reason: Teaching the client about foods high in fiber is not a task that the home health aide can perform. This is a nursing intervention that requires education and evaluation skills.
Choice D reason: Assisting the client to drink warm prune juice is a task that the home health aide can perform. This is a simple and safe measure that can help relieve constipation by stimulating bowel movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the most important intervention, as hypokalemia (low potassium level) can cause life-threatening cardiac arrhythmias and dysrhythmias. The nurse should monitor the client's electrocardiogram (ECG) for signs of abnormal heart rate and rhythm, such as bradycardia, tachycardia, atrial fibrillation, ventricular fibrillation, or asystole.
Choice B reason: This is not a good intervention, as potassium chloride should not be given IV push, as it can cause cardiac arrest. Potassium chloride should be given IV infusion, diluted in a compatible solution, and at a controlled rate, as prescribed by the provider.
Choice C reason: This is a relevant intervention, as hypokalemia can cause muscle weakness, fatigue, and confusion. The nurse should assess the client's level of consciousness (LOC) every 4 hours, and report any changes or deterioration to the provider.
Choice D reason: This is a helpful intervention, as potassium-rich foods can help restore the normal potassium level in the body. The nurse should instruct the client on dietary intake of potassium-rich foods, such as bananas, oranges, potatoes, tomatoes, spinach, yogurt, and nuts. However, this is not the most important intervention, as it may take longer to correct the hypokalemia than IV infusion.
Correct Answer is A
Explanation
Choice A reason: This is the most important intervention, as the client's symptoms suggest a possible myocardial infarction (MI) or angina. The nurse should initiate telemetry and assess the client's cardiac rhythm for any signs of ischemia, injury, or infarction. The nurse should also administer the antianginal medication as prescribed and monitor the client's response.
Choice B reason: This is a relevant intervention, as nausea is a common symptom of MI or angina, especially in women. The nurse should document the description of nausea and administer the antiemetic medication as prescribed. The nurse should also assess the client's abdominal pain and rule out other causes such as gastritis or ulcer.
Choice C reason: This is a necessary intervention, as the verbal prescriptions need to be submitted electronically to the pharmacy and laboratory for processing and verification. The nurse should also document the verbal prescriptions and the read-back process in the client's record. However, this is not the most important intervention, as it can be done after the client's condition is stabilized.
Choice D reason: This is not a priority intervention, as the client's jaw pain is likely related to the cardiac problem and not to a separate issue. The client's pain should be assessed using a standard scale such as the numeric rating scale or the Wong-Baker FACES scale. The nurse should also administer analgesics as prescribed and monitor the client's pain level.
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