During a home visit, the nurse finds that an elderly client has multiple expired medications. What should the nurse do first?

Correct Answer: B

Rationale: In this scenario, the most appropriate initial action for the nurse to take is to review the client's current medication regimen (Option B). This is the correct choice because before addressing the issue of expired medications, the nurse must first assess the client's current medication usage to ensure they are receiving the necessary treatment for their health conditions. Option A, instructing the client to dispose of the expired medications, is not the best first step because it does not address the immediate concern of ensuring the client's current health needs are being met. Additionally, there may be specific disposal protocols that need to be followed for medications. Option C, contacting the client's healthcare provider, while important, should come after assessing the client's current medication regimen. The nurse needs to have a clear understanding of the client's medication history and needs before involving the healthcare provider. Option D, educating the client on the dangers of taking expired medications, is not the priority at this moment. While education is crucial, the immediate focus should be on ensuring the client's current medication regimen is appropriate and addressing any potential gaps in their care. In an educational context, this question highlights the importance of prioritizing client safety and effective nursing assessment in community health settings. Nurses must use critical thinking skills to determine the most appropriate course of action based on the client's needs and the situation at hand. Understanding the sequence of steps in addressing medication concerns is vital for providing quality care in community health nursing practice.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) assess the client's risk for falls. This is the most appropriate initial action for the nurse to take. By assessing the client's risk for falls, the nurse can address immediate safety concerns and prioritize interventions to prevent potential accidents or injuries. Option A) suggesting the client hires a cleaning service may address the cluttered environment but does not directly address the safety issue of falls. Option B) assisting the client in organizing the living space also focuses on the clutter but does not address the immediate risk of falls. Option D) providing the client with information on home safety is important but should come after assessing the specific risk factors present in the client's environment. Educationally, this question highlights the importance of prioritizing interventions based on the immediate needs of the client. Assessing risk factors is fundamental in developing a holistic and individualized care plan, especially in community health nursing where environmental factors play a significant role in overall health and safety. It is crucial for nurses to identify and address safety concerns proactively to promote the well-being of their clients.

Correct Answer: B

Rationale: In this scenario, the correct response is option B: explore the client's dietary habits and challenges. This option is the most appropriate initial action because it allows the nurse to gather crucial information about the client's specific struggles with maintaining a healthy diet. By understanding the client's barriers, preferences, and lifestyle factors influencing their dietary choices, the nurse can tailor interventions effectively. Option A, providing the client with meal planning resources, may be premature without understanding the client's individual needs and obstacles. Option C, referring the client to a nutritionist, is not the first step as the nurse should assess the situation before involving additional healthcare professionals. Option D, educating the client on the importance of a healthy diet, is not as effective as exploring the client's challenges first, as education alone may not address the underlying issues hindering the client's dietary adherence. In the educational context, this question highlights the importance of a client-centered approach in community health nursing. By prioritizing a thorough assessment of the client's needs and challenges, nurses can develop personalized and effective interventions to support clients in achieving optimal health outcomes. This approach aligns with the principles of holistic care and individualized treatment in community health nursing practice.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Hypokalemia. When a client has a nasogastric tube to continuous suction, there is a risk of electrolyte imbalances due to the continuous removal of gastric contents, which can lead to potassium depletion. Potassium is essential for proper nerve and muscle function, including the heart. Monitoring for hypokalemia is crucial to prevent cardiac dysrhythmias and other serious complications in the client. Option A) Hypercalcemia is incorrect because continuous suction would not typically lead to elevated calcium levels. Option C) Hyponatremia is unlikely to occur in this situation as sodium levels are not directly impacted by nasogastric tube suction. Option D) Hypomagnesemia is also incorrect as magnesium levels are not typically affected by the continuous suction of gastric contents. Educationally, understanding the implications of nasogastric tube suction on electrolyte balance is essential for nurses working in community health settings. It highlights the importance of close monitoring and early intervention to prevent potentially life-threatening complications in clients with nasogastric tubes.

Correct Answer: D

Rationale: In this scenario, option D, an International Normalized Ratio (INR) of 2.5, indicates that warfarin therapy is effective for a client with atrial fibrillation. The INR measures the effectiveness of warfarin in thinning the blood to prevent clot formation. An INR within the therapeutic range of 2.0 to 3.0 (or sometimes 2.5 to 3.5) is considered effective in preventing clotting events for patients on warfarin therapy. Option A, an INR of 1.0, is too low and indicates inadequate anticoagulation, putting the client at risk for clotting. Option B, a Prothrombin Time (PT) of 12 seconds, is a measurement of how long it takes for blood to clot and is not specific to monitoring warfarin therapy. Option C, a Partial Thromboplastin Time (PTT) of 60 seconds, is also not used to monitor warfarin therapy but rather to assess other clotting factors. In an educational context, understanding lab values and their significance in monitoring anticoagulant therapy is crucial for nurses in community health settings. Monitoring INR levels helps prevent complications such as stroke or bleeding in patients on warfarin therapy, making it essential for nurses to interpret and act upon these results accurately.