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Question 1 of 5

A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?

Correct Answer: B

Rationale: Nighttime dyspnea suggests acute heart failure exacerbation, requiring priority.

Question 2 of 5

The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:

Correct Answer: D

Rationale: Cupped hands during chest percussion create a vibration that helps loosen mucus in cystic fibrosis without causing injury.

Question 3 of 5

A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?

Correct Answer: B

Rationale: Pulling a toy is consistent with an 18-month-old's developmental level, supporting the assessment.

Question 4 of 5

A client has been instructed in the application and use of anti-embolic compression stockings. Which of the following statements by the client indicates a need for more teaching? Select all that apply.

Correct Answer: A,B,D

Rationale: Rolling the top down (
A) can impede circulation, removing stockings every 1-2 days (
B) is too infrequent (should be every 8 hours), and baby powder (
D) can cause skin irritation. Turning the stocking inside out (
C) and preventing clots (E) are correct.

Question 5 of 5

A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client's discharge care plan?

Correct Answer: C

Rationale: Phenytoin requires regular blood work to monitor levels and prevent toxicity, which can cause side effects like gingival hyperplasia.

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The nurse recognizes all of the following as type IV hypersensitivity reactions EXCEPT

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