EL MINISTRO DE PÚBLICAS Y TRANSPORTES RESUELVE:

8. Which information should the experienced HH nurse discuss when orienting a new nurse to HH nursing?

1. If the client or family is hostile or obnoxious, call the police. 2. Carry the HH care agency identification in a purse or wallet. 3. Visits can be scheduled at night with permission from the agency. 4. Inform the agency of the times of the client’s scheduled visits.

9. The client with a sigmoid colostomy has an excoriated area around the stoma that has not improved for more than 2 weeks. Which intervention is most appropriate for the HH nurse to implement?

1. Refer the client to the wound care nurse. 2. Notify the client’s health-care provider. 3. Continue to monitor the stoma site. 4. Place Karaya paste over the excoriated area.

10. The HH nurse is admitting a female client diagnosed with end-stage renal disease who refuses to be placed on hemodialysis. The client is ready to die but verbalizes having so many regrets in her life. Which intervention would be most appropriate for the nurse?

1. Contact the agency chaplain to come talk to the client. 2. Call her church pastor and discuss the client’s concerns. 3. Ask the client whether she would like to pray with the nurse. 4. Determine whether the client has an Advance Directive.

11. The HH agency director of nursing is making assignments for the nurses. Which client should be assigned to the HH nurse new to HH nursing?

1. The client diagnosed with AIDS who is dyspneic and confused. 2. The client who does not have the money to get prescriptions filled.

3. The client with full-thickness burns on the arm who needs a dressing change. 4. The client complaining of pain who is diagnosed with diabetic neuropathy.

12. The HH nurse along with an HH aide is caring for a client who is 3 week postopera- tive for open reduction and internal fixation of a right hip fracture. Which task would be appropriate for the nurse to delegate to the aide?

1. Instruct the HH aide to palpate the right pedal pulse. 2. Ask the HH aide to change the right hip dressing. 3. Tell the HH aide to elevate the right leg on two pillows. 4. Request the HH aide to mop the client’s bedroom floor.

13. The HH nurse tells the director of the HH care agency that the nurses are upset and arguing over how the clients are being assigned by the assistant director. Which statement indicates a democratic leadership style?

1. “My assistant makes the assignments and I support how she does it.” 2. “As long as there are no complaints from the clients I will not interfere.” 3. “I appreciate you telling me about the situation and I will handle it.”

4. “I will schedule a meeting and we will all sit down and discuss the situation.”

14. The HH aide tells the HH nurse that the grandson of the client she is caring for asked her out on a date. Which statement is the HH nurse’s best response? 1. “I am so excited for you; he seems like a very nice young man.”

2. “You should not go out with him as long as she is a client of our agency.” 3. “I think you should tell the director of the HH care agency about this date.” 4. “You should never date someone you meet while taking care of a client.”

15. The HH nurse’s primary responsibility is teaching the client diagnosed with conges- tive heart failure. Which teaching interventions should the nurse discuss with the client? Select all that apply.

1. Notify the HCP if the client gains more than 2 lbs in one day. 2. Keep the head of the bed elevated when sleeping.

3. Take the loop diuretic once a day before going to sleep.

4. Teach the client which foods are high in sodium and should be avoided. 5. Perform isotonic exercises at least once a day.

16. The client tells the HH nurse, “My oncologist told me they can’t do anything else for my cancer. I do not want my children to know, but I had to tell someone. You won’t tell them, will you?” Which statement is the nurse’s best response?

1. “Since you told me about the prognosis, I must talk to your children.” 2. “I don’t think it is a good idea not to tell your children; they should know.” 3. “I will not say anything to your children, but I will contact the HH doctor.” 4. “You are concerned I might talk to your children about your prognosis.”

17. The male client with peripheral vascular disease tells the female HH nurse, “I know my foot is really bad. My doctor told me I don’t have any choice and I must have an amputation, but I don’t want one.” Which action supports the HH nurse’s being a client advocate?

1. Support the medical treatment, and recommend he have the amputation. 2. Recommend the client talk to his wife and children about his decision.

3. Explain that he has a right to a second opinion if he doesn’t want an amputation. 4. Tell the client she will go with him to discuss his decision with the doctor.

18. The multidisciplinary team is meeting to discuss a client with right-sided weakness who has developed a pressure ulcer over the sacral area that is not healing. Which priority intervention should the client’s HH nurse recommend?

1. Recommend the client get a hospital bed with a trapeze bar. 2. Recommend an HH aide provide care 7 days a week for the client. 3. Recommend the client’s being transferred to a skilled nursing unit. 4. Recommend a referral to the HH care agency wound care nurse.

19. The HH aide tells the HH nurse that the client is having problems getting out of the bed to the chair and is now having problems getting into the shower. Which intervention should the nurse implement?

1. Ask the HH aide whether the bathroom has grab bars. 2. Assess the client’s ability to transfer in the home. 3. Instruct the HH aide to give the client a bed bath. 4. Contact the agency physical therapist about the situation.

20. The female HH nurse finds that the client is not at home at the scheduled time. The neighbor told the nurse the client went to the mall to do some shopping. Which intervention is most appropriate?

1. Tell the neighbor to inform the client she was at the home.

2. Notify the agency that the client should be discharged from service. 3. Leave a note on the client’s door that the HH nurse was there. 4. Reschedule the visit when it is convenient for the client.