Nursing Elites

1. The client with newly diagnosed type 1 diabetes mellitus is being taught about insulin administration by the nurse. Which statement indicates that the client needs further teaching?

• A. I will inject my insulin into my abdomen for the fastest absorption.
• B. I will rotate injection sites to prevent lipodystrophy.
• C. I will store my insulin in the refrigerator at all times.
• D. I will rotate injection sites to prevent lipodystrophy.

Correct answer: C

Rationale: The correct answer is C. Insulin should not be stored in the refrigerator at all times; it should be kept at room temperature when in use to avoid irritation at the injection site. Storing insulin in the refrigerator can cause it to thicken and may lead to discomfort upon injection. Choices A and D are correct statements as injecting insulin into the abdomen for faster absorption and rotating injection sites to prevent lipodystrophy are appropriate insulin administration techniques. Therefore, the client does not need further teaching on these aspects.

2. An elderly client with a history of falls is being discharged from the hospital. Which intervention should the home health nurse implement to reduce the client's risk of falling at home?

• A. Install grab bars in the bathroom
• B. Provide a walker for ambulation
• C. Educate the client on fall prevention strategies
• D. Refer the client to a physical therapist

Correct answer: A

Rationale: Installing grab bars in the bathroom is crucial to reducing the elderly client's risk of falling at home. Grab bars provide physical support and stability, especially in areas like the bathroom where slips and falls are common among older adults. While providing a walker for ambulation (Choice B) can assist with mobility, it may not directly address the environmental hazards at home. Educating the client on fall prevention strategies (Choice C) is important but may not be sufficient if the physical environment is not modified to reduce fall risks. Referring the client to a physical therapist (Choice D) may help improve strength and balance but does not directly address the immediate environmental risk of falling at home.

3. During a home visit, the nurse observes that an elderly client has a cluttered living environment and poor lighting. What should the nurse do first?

• A. suggest that the client hires a cleaning service
• B. assist the client in organizing the living space
• C. assess the client's risk for falls
• D. provide the client with information on home safety

Correct answer: C

Rationale: The correct first action for the nurse to take is to assess the client's risk for falls. A cluttered living environment and poor lighting are significant risk factors for falls in the elderly. By assessing the client's risk for falls, the nurse can identify potential hazards and implement appropriate interventions to prevent falls. Suggesting hiring a cleaning service or assisting in organizing the living space may address the symptoms but not the root cause of the fall risk. Providing information on home safety is important but should come after assessing the specific risk factors for falls in this scenario.

4. An older client requiring total care resides with a family consisting of two daughters who take shifts providing care around-the-clock. During a home visit, the daughters ask the nurse about resources that are available for client care while they attend a scheduled family reunion. Which information is best for the nurse to provide?

• A. propose the family seek assistance for care in the area of the reunion's location
• B. tell the caregivers to consider hiring a private duty nurse during the time away
• C. advise to have a case management evaluation of the client's home environment
• D. suggest social services be contacted to find a respite care facility for the client

Correct answer: D

Rationale: Respite care provides temporary relief for primary caregivers, allowing them to attend the reunion while ensuring the client is cared for.

5. The nurse must delegate some aspects of a homebound client's care to a home health aide. Which intervention should the nurse delegate to the home health aide?

• A. evaluating a pressure sore
• B. applying a prosthetic device
• C. performing a sterile dressing change
• D. assessing the client's need for an elevated toilet seat

Correct answer: B

Rationale: The correct answer is B: applying a prosthetic device. Home health aides are trained and authorized to assist with the application and management of prosthetic devices for clients. Evaluating a pressure sore (choice A) requires clinical assessment and judgment typically performed by a licensed healthcare provider such as a nurse. Performing a sterile dressing change (choice C) involves aseptic technique and wound care skills that are usually performed by licensed healthcare professionals. Assessing the client's need for an elevated toilet seat (choice D) involves a level of assessment and decision-making that is beyond the scope of practice for a home health aide.

Similar Questions