The home health nurse enters the home of a client, and the client's spouse immediately reports that the client cannot be awakened and appears to have taken an overdose of some medications. After determining that the client is unresponsive but is breathing and has a pulse, which action should the nurse take?

Call 911 for emergency transport.

Determine what medications were ingested.

Contact the poison control center.

Attempt to induce vomiting using a tongue blade.

Answer and Explanation

The Correct Answer is A

A) Call 911 for emergency transport:
The client is unresponsive, which is a critical situation requiring immediate medical attention. Even though the client is breathing and has a pulse, the unresponsiveness suggests a potentially severe overdose that could rapidly deteriorate. Calling 911 ensures that emergency medical services are on their way to provide advanced care and transport to a facility where further treatment can be administered.

B) Determine what medications were ingested:
While knowing what medications were taken is important for treatment, the immediate priority is to address the client’s unresponsiveness. Identifying the medications can be done once the client is stabilized or while awaiting emergency services, but it does not replace the need for urgent medical intervention.

C) Contact the poison control center:
Contacting the poison control center is useful for guidance on managing an overdose, but it should be done in conjunction with calling 911 if the client is unresponsive. The poison control center can provide specific treatment advice, but immediate emergency medical assistance is crucial for the client’s safety.

D) Attempt to induce vomiting using a tongue blade:
Inducing vomiting can be dangerous, especially if the client is unresponsive or has an impaired airway. Attempting to induce vomiting without professional medical support could lead to aspiration or other complications. The priority is to ensure the client receives proper medical care through emergency services.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","F"]

Explanation

A) Client survey both in clinic and in the home:
Conducting surveys in both the clinic and home settings provides a comprehensive approach to gathering data on vaccination rates and influenza cases. This method ensures a wider reach and captures information from diverse populations, which can help in understanding factors influencing vaccination rates.
B) Ask a set number of clients if they have had the flu:
This action is less systematic and may not provide comprehensive data on vaccination rates or trends. It focuses more on individual experiences rather than providing a broad analysis of vaccination coverage and influenza cases.
C) Determine change in immunization rates from prior year to current year:
Analyzing the change in immunization rates over time helps identify trends and patterns. This comparison will reveal whether there has been a decline in vaccination rates, which could correlate with the increase in influenza cases. This step is crucial for understanding the effectiveness of past vaccination efforts and identifying areas for improvement.

D) Generate influenza immunization and case reports from the electronic record for prior year and current year:
Generating and reviewing reports from electronic health records provides concrete data on immunization rates and influenza cases. This data is essential for identifying trends and making informed decisions about where and how to target interventions.

E) Develop an action plan to increase immunization rates:
While developing an action plan is a necessary step after analyzing the data, it is not part of the data gathering process itself. It comes after understanding the current trends and patterns from the data collected.
F) Delineate geographic distribution of area to survey and review for patterns:
Understanding the geographic distribution helps in identifying areas with higher or lower vaccination rates and influenza cases. This spatial analysis can reveal patterns related to vaccination coverage and infection rates, guiding targeted interventions and resource allocation.

A. Explain to the client results should be read between 48 and 72 hours. B. Identify how the client will follow up to have the results read. C. Determine if the client understands the purpose of the tuberculin test. D. Give the client written Information about the tuberculosis test.

Correct Answer is B

Explanation

A) Explain to the client results should be read between 48 and 72 hours:
While it is important for the client to know when the results should be read, this step is secondary to ensuring the client has a plan for follow-up. Knowing the timeline for reading the results alone does not guarantee that the client will actually return to have the test read.

B) Identify how the client will follow up to have the results read
Ensuring that the client has a clear plan for follow-up is the most crucial intervention. For a homeless client, arranging for follow-up might involve coordinating with local health services or shelters to make sure the client returns for the test reading. Without a solid follow-up plan, the TB test could be missed, which is important for ensuring proper diagnosis and treatment.

C) Determine if the client understands the purpose of the tuberculin test:
Understanding the purpose of the test is important for client education, but it does not directly address the issue of follow-up. The priority should be ensuring that the client knows how to get the test results read, which is essential for the test's effectiveness.

D) Give the client written information about the tuberculosis test
Providing written information can be helpful, but it does not guarantee that the client will follow up to have the test read. Given the challenges faced by homeless individuals, direct assistance in planning follow-up care is more critical than providing written information alone.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D","F"]

Explanation

A homeless client with alcohol dependency will be dismissed from the emergency department in 24 hours. The nurse notes that a tuberculin (TB) skin test was prescribed by the healthcare provider. Which intervention is most important for the nurse to implement prior to discharge?

Correct Answer is B

Explanation

Several clients who have recently come to the local health clinic in a rural county are diagnosed with tuberculosis (TB). After reporting the occurrence to the health department, which community focused action should the nurse implement first?

Community health nurses are particularly concerned with the spread of communicable diseases such as hepatitis A. Which group of Individuals should the nurse identify as being at greatest risk for contracting this type of hepatitis?

A migrant farm worker who lives in a mobile home with several other workers visits the Migrant Health Care Center. The client reports Increasing episodes of dizziness, headaches, abdominal cramps, and difficulty breathing. Which nursing action has the highest priority?

When assessing the health of a community, which is the most important information for the nurse to obtain?

A 66-year-old client is retiring and will no longer have health insurance through a place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?

The nurse is planning a health fair for high school students. Which assessment is most important for the nurse to obtain?

The city health department director asks the community health nurse to make a presentation describing the greatest health concern facing the city. How should the nurse begin to collect the data needed for this presentation?

On a day when the temperature is expected to drop to below freezing during the night, the nurse is asked to determine which homeless adults are most in need of the limited spaces that are available in a shelter. It is most important for which person to be admitted for the night?