The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Shufling gait.

Urinary incontinence.

Syncope when bending.

Hand tremors.

Answer and Explanation

Correct Answer : A,C,D

The correct answer is Choice A, Choice C, and Choice D.

Choice A rationale: A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.

Choice B rationale: Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.

Choice C rationale: Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.

Choice D rationale: Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.

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Correct Answer is C

Explanation

Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.

Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.

Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.

Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.

A. Praise the UAP for using standard precautions. B. Instruct the UAP to change gloves immediately. C. Request that an in-service program be scheduled on asepsis. D. Submit an adverse occurrence report to the unit manager.

Correct Answer is B

Explanation

Choice A reason: Praising the UAP for using standard precautions is not appropriate in this situation as using the same gloves for multiple clients breaches infection control protocols.

Choice B reason: The nurse should instruct the UAP to change gloves immediately to prevent cross-contamination between clients.

Choice C reason: While scheduling an in-service program on asepsis is beneficial for long-term education, it does not address the immediate risk of infection.

Choice D reason: Submitting an adverse occurrence report may be necessary if there is a pattern of non-compliance, but the first action should be to correct the behavior and ensure client safety.

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The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

Correct Answer is C

Explanation

The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

Correct Answer is B

Explanation

Exhibits What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?

A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.

A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?