Question

A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-inclusive Care for the Elderly (PACE) for which of the following clients?

Answer 1

Correct Answers:

A client who requires transfer to a skilled care facility

Rationale :

💡PACE provides comprehensive health services to older adults who require long-term care but wish to remain in their communities rather than be institutionalized.

🏠The program is designed for clients eligible for nursing home–level care but who can still live safely at home with support.

🩺It coordinates medical, social, and rehabilitative services, including skilled nursing, physical therapy, and nutritional counseling.

🤝Therefore, a client requiring skilled facility care qualifies for PACE to receive all-inclusive, community-based services.

📌Core Message

The PACE program supports older adults needing nursing-level care but desiring to stay in the community with coordinated services.

Answer 2

Correct Answers:

Oxytocin

Rationale :

🩸A boggy fundus and heavy lochia indicate uterine atony, a major cause of postpartum hemorrhage.

💊Oxytocin promotes uterine contraction to control bleeding and restore uterine tone.

🚫Nalbuphine is an analgesic and not used for postpartum hemorrhage management.

⚕️Terbutaline and magnesium sulfate are uterine relaxants, which would worsen bleeding.

📌Core Message

Oxytocin is used to manage uterine atony by promoting uterine contractions and preventing hemorrhage.

Answer 3

Correct Answers:

Assist client with oral care.

Rationale :

🧼Assistive personnel (AP) can perform basic care tasks under the supervision of a nurse.

👩‍⚕️Tasks requiring teaching, evaluation, or assessment remain the nurse’s responsibility.

🦷Oral care is a routine, noninvasive activity suitable for delegation to an AP.

📞Tasks like instructing family or evaluating pain relief require nursing judgment and cannot be delegated.

📌Core Message

Delegation to an AP involves basic, non-assessment tasks such as assisting with oral care.

Answer 4

Correct Answers:

Keeps the head of the bed elevated to 45° for 1 hr after feedings

Rationale :

💁‍♂️Keeping the head of the bed elevated reduces the risk of aspiration during and after enteral feeding.

🧪Instilling 100 mL of air is excessive; only 30 mL of air is needed to check placement.

🔵Blue dye should never be added to feedings because it can cause toxicity and false aspiration results.

💧Routine irrigation should be done with water, not continuous 0.9% saline, to maintain tube patency safely.

📌Core Message

Elevating the head after feeding helps prevent aspiration and supports safe NG tube feeding.

Answer 5

Correct Answers:

"Sedation is a common adverse effect of this medication."

Rationale :

💤Methadone is a long-acting opioid agonist used for opioid dependence management.

🧠It can cause sedation, constipation, and respiratory depression as side effects.

💁‍♂️Clients should not stop methadone abruptly, especially during pregnancy, as it can cause withdrawal and fetal distress.

⚕️Doubling doses increases risk of toxicity; dosing should be strictly scheduled.

📌Core Message

Methadone may cause sedation, and doses must be taken as prescribed to prevent withdrawal or overdose.

Answer 6

Correct Answers:

Determine the client's perception of the personal impact of the crisis.

Rationale :

🧩In crisis intervention, the nurse must first assess the client’s perception to guide further actions.

💬Understanding how the client interprets the event helps determine coping ability and emotional state.

🏥Safety comes first, but after safety is ensured, assessment precedes intervention in the nursing process.

🧠Only after identifying the emotional response can appropriate referrals or coping support be provided.

📌Core Message

In crisis care, once safety is secured, the nurse should first assess the client’s perception of the event.

Answer 7

Correct Answers:

Establish the termination date of therapy.

Rationale :

🕊️During the orientation phase, the nurse focuses on building trust and defining the boundaries of the relationship.

📆Discussing the termination date early promotes transparency and trust.

🧭Other actions like problem-solving or self-esteem promotion belong to the working phase.

🤝This phase aims to clarify expectations, roles, and confidentiality to establish a therapeutic connection.

📌Core Message

The orientation phase focuses on establishing boundaries and trust through clarity about termination and expectations.

Answer 8

Correct Answers:

Uncompensated respiratory acidosis

Rationale :

🧪A low pH (7.3) and high PaCO₂ (54 mm Hg) indicate respiratory acidosis.

🌬️This occurs when CO₂ retention leads to acid accumulation due to hypoventilation in COPD.

💉The HCO₃ is normal (26 mEq/L), showing no compensation by the kidneys yet.

📉Low SaO₂ (87%) supports hypoxia from poor gas exchange.

📌Core Message

In COPD, a low pH and high CO₂ reflect uncompensated respiratory acidosis due to CO₂ retention.

Answer 9

Correct Answers:

Irritability

Rationale :

🧠Hypoglycemia causes decreased glucose availability to the brain, leading to irritability, confusion, and tremors.

💉Other signs include sweating, palpitations, and hunger due to sympathetic activation.

🚫Polyuria and vomiting are symptoms of hyperglycemia, not hypoglycemia.

🌡️Facial warmth is unrelated to glucose level changes.

📌Core Message

Irritability is an early CNS symptom of hypoglycemia due to low brain glucose.

Answer 10

Correct Answers:

Cut the skin barrier opening 0.6 cm (0.24 in) larger than the stoma.

Rationale :

✂️The skin barrier should fit snugly around the stoma to protect the skin and allow movement.

🩹Cutting it 0.3–0.6 cm larger prevents restriction while avoiding leakage.

💁‍♂️Using povidone-iodine irritates the skin and delays healing.

💧The skin must be clean and dry before applying the barrier for proper adhesion.

📌Core Message

Proper colostomy care requires cutting the skin barrier slightly larger than the stoma to ensure comfort and seal integrity.

1 :
A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-inclusive Care for the Elderly (PACE) for which of the following clients?

2 :
A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. Which of the following medications should the nurse expect to administer?

3 :
A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

4 :
A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse Indicates an understanding of the procedure?

5 :
A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching?

6 :
A nurse is Interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first?

7 :
A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship?

9 :
A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor fur which of the following findings as a manifestation of hypoglycemia?

10 :
A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take?

1 : A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-inclusive Care for the Elderly (PACE) for which of the following clients?

2 : A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. Which of the following medications should the nurse expect to administer?

3 : A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

4 : A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse Indicates an understanding of the procedure?

5 : A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching?

6 : A nurse is Interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first?

7 : A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship?

8 : A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3 (7.35 to 7.45), Pa0, 56 mm Hg (80 to 100 mm Hg) PaCO2 54 mm Hg (35 to 45 mm Hg), HCO3 26 mEq/L (21 to 28 mEq/L), and SaO2 87%. Which of the following is the correct interpretation of these values?

9 : A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor fur which of the following findings as a manifestation of hypoglycemia?

10 : A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take?

1 :
A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-inclusive Care for the Elderly (PACE) for which of the following clients?

2 :
A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. Which of the following medications should the nurse expect to administer?

3 :
A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

4 :
A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse Indicates an understanding of the procedure?

5 :
A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching?

6 :
A nurse is Interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first?

7 :
A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship?

9 :
A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor fur which of the following findings as a manifestation of hypoglycemia?

10 :
A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take?