A home health nurse is making an initial visit to an

A home health nurse is making an initial visit to an older adult client who has COPD
and is receiving oxygen. While assessing the home environment for safety, which of

the following findings should the nurse recognize as increasing the client's risk for
injury?
An office chair with wheels at the client's computer desk.
- Wheeled chairs create a safety hazard for the client because he may fall
while sitting and rising from the chair, especially while managing oxygen
equipment.
An oxygen tank standing on the floor next to the client's recliner.
- The client should always keep the oxygen tank in a rack or stand.
Otherwise, it is easy to knock it over and risk sudden decompression and
uncontrolled movement of the tank, which could cause injury.
A throw rug over vinyl flooring in the client's bathroom.
- Covering flooring with a throw rug can increase the client's risk for falls.
An 18-year-old client in remission with rhabdomyosarcoma has just been diagnosed
with metastasis to the bone. The client says that he does not want to have
chemotherapy again. Which of the following statements is consistent with the
client's rights?
The nurse states, "I can gather information about palliative care for you."
- The nurse is acknowledging the client's right to refuse treatment and is
demonstrating support by offering to discuss end-of-life care options.
A charge nurse is delegating tasks on a nursing unit that is short staffed. A client
has a prescription for a wound irrigation twice a day. Which of the following actions
should the charge nurse take?
Assign the procedure to a licensed practical nurse (LPN).
- This task is within the scope of practice of an LPN. The charge nurse should
delegate this task to the LPN.
A nurse manager confronts a nurse who has the smell of alcohol on her breath. After
the nurse is sent home, which of the following actions should the nurse manager
take?
Set up a formal meeting with the nurse within 24 hr.
- Once the nurse manager has removed the nurse from the work environment
and arranged for safe transportation home, the nurse manager should
arrange to meet with the nurse within the next 24 hours. The nurse manager
is to confront the nurse who was chemically impaired and clearly identify the
facility's expectations.
A nurse is receiving report on four clients. Which of the following clients should the
nurse plan to assess first?

A client who has a potassium level of 6.5 mEq/L
- When using the acute vs. chronic approach to client care, the nurse should
first assess the client who is at risk for cardiac dysrhythmias; therefore, the
nurse should assess the client who has a potassium level of 6.5 mEq/L which
indicates hyperkalemia. Cardiac complications of hyperkalemia can include
bradycardia, hypotension, complete heart block, and can lead to asystole.