the home health nurse has made a visit to an 85 year old female clients home who has recently had surgery to replace her left knee the client has been

NCLEX-PN

NCLEX PN Practice Questions Quizlet

1. The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

A. The client should remove all scatter rugs from the floor and minimize clutter.
B. The client should not limit her movement within the home unless advised by the physician.
C. The client should have a raised toilet seat and grab bars available in the bathroom.
D. The client should not wear a robe and socks while walking in the house.

Correct answer: A

Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.

2. Why is Kleinman's Explanatory Model of Health and Illness significant?

A. it focuses on the health beliefs of a particular family.
B. it highlights the impact of culture on health explanations.
C. it discusses the significant role of popular and folk domains of influence.
D. it is based on an educational approach.

Correct answer: C

Rationale: Kleinman's Explanatory Model of Health and Illness is significant because it emphasizes the influence of popular and folk domains on health perceptions. Kleinman distinguishes between disease, representing the biomedical view, and illness, reflecting individual understanding. The model underscores that cultural factors shape the significance of popular and folk influences on health beliefs. Choice A is incorrect as the model focuses on broader cultural influences, not individual family beliefs. Choice B is incorrect as it oversimplifies the model's emphasis on various cultural aspects. Choice D is incorrect as the model's significance lies in its cultural framework rather than an educational base.

3. A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope on which part of the client's chest?

A. Second left interspace
B. Second right interspace
C. Left lower sternal border
D. Fifth left interspace at the midclavicular line

Correct answer: D

Rationale: The correct placement for auscultating the apical heart rate in the area of the mitral valve is the fifth left interspace at the midclavicular line. Placing the stethoscope in the second left interspace would be to listen to the pulmonic valve, the second right interspace is for the aortic valve, and the left lower sternal border is for the tricuspid valve.

4. The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:

A. administer both medications simultaneously
B. give the medications sequentially, and flush well between them
C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug
D. start one medication now and begin the other medication in 2-4 hours

Correct answer: B

Rationale: The correct answer is to give the medications sequentially and flush well between them. Ampicillin has a pH of 8-10, while gentamicin has a pH of 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent any potential interactions. Option A is incorrect because administering both medications simultaneously can lead to incompatibility issues. Option C is incorrect because the nurse should already be aware of the correct administration sequence and not need to consult the physician or pharmacy each time. Option D is incorrect because delaying the second medication by several hours can slow down the treatment of the client's infection, which is not ideal in this scenario.

5. An amniocentesis is scheduled for a pregnant client in the third trimester. The nurse informs the client that the most common indication for amniocentesis during the third trimester is for which reason?

A. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid
B. Checking the amniotic fluid for intrauterine infection
C. Determination of fetal lung maturity
D. Checking the fetal cells for chromosomal abnormalities

Correct answer: C

Rationale: The most common indication for amniocentesis in the third trimester is the determination of fetal lung maturity. This assessment is essential to evaluate the fetus's readiness for extrauterine life. Checking for alpha-fetoprotein (AFP) in the amniotic fluid is more commonly associated with midtrimester amniocentesis to identify chromosomal abnormalities. Assessing for intrauterine infection is not a primary reason for amniocentesis in the third trimester. While checking fetal cells for chromosomal abnormalities is a common indication for midtrimester amniocentesis, it is not the most common indication in the third trimester.