CS 6 - Home Health Flashcards
The nurse who is working for the home health division of a public health agency arrives
for the day with plans to make home visits to six patients:
Ms. A
Diagnosis: Chronic obstructive pulmonary disease (COPD)
Data:
• Called reporting increased dyspnea
• Has been increasing home oxygen flow rate
Mr. D
Diagnoses: Diabetes, chronic leg infection
Data:
• Needs weekly assessment of leg infection
• Daily home health aide visits
Ms. F
Diagnosis: Chronic kidney disease with peritoneal dialysis
Data:
• Daughter assists patient with dialysis
Mr. I
Diagnosis: Lung cancer
Data:
• Last chemotherapy 1 week ago
• Needs to have blood drawn today at nadir for complete blood count (CBC) with
differential
Ms. R
Diagnosis: Coronary artery disease with percutaneous coronary angioplasty and
stenting
Data:
• Hospital discharge yesterday
• Needs home health admission assessment
Mr. W
Diagnosis: Schizophrenia
Data:
• Receives risperidone injection every 4 weeks
• Risperidone dose scheduled today
After arriving, the nurse learns about a required case management in-service
scheduled for 2:00 pm , which will leave time for only four home visits. Which
four patients should be scheduled for today?
1. Ms. A
2. Mr. D
3. Ms. F
4. Mr. I
5. Ms. R
6. Mr. W
Ans: 1, 4, 5, 6 Ms. A’s dyspnea and increased use of oxygen require rapid
assessment. Mr. I’s sample for a CBC must be drawn when the bone marrow
is most suppressed to accurately assess the impact of chemotherapy on bone
marrow function. Ms. R should be seen as soon as possible after discharge to
determine the plan of care. Mr. W needs to receive the scheduled dose of
risperidone. Mr. D and Ms. F do not have urgent needs, and these visits can
be rescheduled for the following day. Focus: Prioritization.
The nurse who is working for the home health division of a public health agency arrives
for the day with plans to make home visits to six patients:
Ms. A
Diagnosis: Chronic obstructive pulmonary disease (COPD)
Data:
• Called reporting increased dyspnea
• Has been increasing home oxygen flow rate
Mr. D
Diagnoses: Diabetes, chronic leg infection
Data:
• Needs weekly assessment of leg infection
• Daily home health aide visits
Ms. F
Diagnosis: Chronic kidney disease with peritoneal dialysis
Data:
• Daughter assists patient with dialysis
Mr. I
Diagnosis: Lung cancer
Data:
• Last chemotherapy 1 week ago
• Needs to have blood drawn today at nadir for complete blood count (CBC) with
differential
Ms. R
Diagnosis: Coronary artery disease with percutaneous coronary angioplasty and
stenting
Data:
• Hospital discharge yesterday
• Needs home health admission assessment
Mr. W
Diagnosis: Schizophrenia
Data:
• Receives risperidone injection every 4 weeks
• Risperidone dose scheduled today
After adjusting the schedule to see these four patients, which patient should
be seen first?
1. Ms. A, the patient who has COPD and increased shortness of breath
2. Mr. I, the patient receiving chemotherapy who will need blood drawn
3. Ms. R, the patient with coronary artery disease who will need an initial
assessment
4. Mr. W, the patient with schizophrenia who will need a risperidone injection
Ans: 1 Ms. A’s increased shortness of breath indicates a need for rapid
assessment. In addition, high oxygen flow rates can cause an increase in the
partial pressure of carbon dioxide (Paco 2 ) and suppression of respiratory
drive in patients with COPD, so Ms. A should be seen as soon as possible.
The other patients can be scheduled according to criteria such as location or
patient preference about visit time. Focus: Prioritization.
When the nurse calls Ms. R to schedule a visit, the patient says that she
doesn’t have much time today but will be available for a longer visit
tomorrow. What is the best response?
1. “The visit will not take very long, so I will plan on seeing you today.”
2. “I have rescheduled other patients because it is essential that I assess you
today.”
3. “Perhaps you are feeling that you do not really need any help at home.”
4. “Because of the recent angioplasty and stenting, I would like to visit as
soon as possible.”
Ans: 4 In the home health setting, the patient is in control of health
management, so enlisting the patient’s cooperation for the visit is essential. In
this response, the nurse indicates that the patient has a choice about whether
the visit is scheduled for today but educates the patient about why it is
important that the visit occur as soon as possible. Because the initial visit
requires a multidimensional assessment, it is usually quite lengthy. The
patient’s comments do not indicate a lack of need or desire for home health
services. Focus: Prioritization.
After obtaining Ms. R’s consent for a visit later today, the nurse arrives at Ms. A’s
home. Her husband answers the door and says that Ms. A was very short of breath and
restless last night, but now she is sleeping deeply and completely relaxed. The nurse
finds that Ms. A is very difficult to awaken and that her speech is slurred. The flow
meter on her home oxygen unit is set at 6 L/min.
Which nursing action should the nurse take next?
- Auscultate Ms. A’s anterior and posterior lung sounds.
- Check Ms. A’s oxygen saturation using pulse oximetry.
- Continue to stimulate Ms. A until she can respond to you.
- Notify the health care provider (HCP) about Ms. A’s change in status.
Ans: 2 The patient has symptoms and risk factors that could indicate that her
oxygen saturation is either excessively high or too low, so checking oxygen
saturation is the first action that should be taken. The other actions may also
be appropriate, but assessment of oxygen saturation will determine which
action should occur next. Focus: Prioritization.
The oxygen saturation is 99% per pulse oximeter. Which action is appropriate
next?
4951. Discontinue the patient’s oxygen.
2. Draw a sample for arterial blood gas analysis.
3. Call the HCP and obtain an order to transport Ms. A to the hospital.
4. Remind the patient’s husband about the reasons for using oxygen at low
flow rates.
Ans: 1 Since the goal for oxygen saturation for a patient with COPD is usually
90% to 94% (0.90 to 0.94), because high oxygen levels can decrease respiratory
drive and lead to increases in Paco 2 , the nurse’s first action should be to
discontinue the oxygen for this patient. The next step is to notify the HCP,
who may want to admit the patient to the hospital or order arterial blood gas
analysis. It will be important to discuss appropriate home oxygen use with
the patient and her husband but not until the immediate situation is resolved.
Focus: Prioritization; Test Taking Tip: Remember that some patients with
COPD may have a decrease in respiratory drive if oxygen saturations are
elevated. Although administration of a high oxygen percentage may be
necessary if the patient is hypoxemic, you will need to monitor the patient’s
oxygen saturation carefully and adjust the oxygen flow rate down as the
patient’s oxygen saturation improves.
The nurse calls the HCP to discuss Ms. A’s status and then arranges for her admission
to the hospital for further evaluation.
The nurse receives a phone call from Mr. D’s home health aide, who reports that Mr.
D is experiencing generalized aches and pains. His morning blood glucose level was
306 mg/dL (16.98 mmol/L), and his temperature is 100.1°F (37.8°C).
6. Which action by the nurse is most appropriate?
1. Suggest that Mr. D take acetaminophen to treat pain and fever.
2. Arrange to see Mr. D as the first patient on tomorrow’s schedule.
3. Reorganize today’s schedule so that Mr. D can be seen and assessed.
4. Reassure the aide that these findings are normal for patients with diabetes.
Ans: 3 Generalized aches and pains, an elevated temperature, and an elevated
500glucose level are signs of infection in patients with diabetes, indicating a
significant change in the patient’s status and need for further assessment.
Acetaminophen may be indicated for discomfort but will not treat infection.
Because diabetes decreases immune function and increases the risk for
serious infections, the nurse should not wait another day before seeing the
patient. Focus: Prioritization.
Because Mr. D will be visited today, which of the three patients that are
scheduled for today is best to reschedule for tomorrow?
1. Mr. I, who is receiving chemotherapy and needs a blood specimen drawn
2. Ms. R, who needs an initial home health visit after coronary artery stenting
3. Mr. W, who is scheduled for an injection of risperidone to treat
schizophrenia
Ans: 3 Although the risperidone is scheduled for today, the medication is
absorbed gradually, and rescheduling the dose for tomorrow will not have an
adverse impact on control of the patient’s schizophrenia. The other patients
have more urgent needs and should receive visits today. Focus: Prioritization.
The nurse arrives at Ms. R’s home as arranged, and the patient is waiting at
the door. Her respiratory effort seems a little labored, and she looks anxious.
The nurse asks Ms. R how she has been feeling since her discharge from the
hospital yesterday. Which response indicates a need for immediate
intervention?
1. “I have been a bit short of breath.”
2. “I feel some left-sided chest pressure.”
3. “I don’t understand why I need to take all these pills.”
4. “I am confused about why you are here to see me.”
Ans: 2 The chest pressure indicates that Ms. R may be experiencing
myocardial ischemia and requires immediate assessment and intervention
(e.g., administration of sublingual nitroglycerin). The shortness of breath
requires further investigation and is likely to related to the chest pressure and
myocardial ischemia. The other responses also indicate the need for further
assessment and interventions such as teaching but do not require immediate
action. Focus: Prioritization; Test Taking Tip: Report of chest pain or chest
pressure in a patient with known coronary artery disease is a red flag that
requires immediate assessment and intervention. Do not minimize this
finding or allow the patient to minimize the symptom. Remember that angina
signifies coronary ischemia and the goal for treatment is that chest discomfort
is completely absent (0 on a 1–10 scale).
Five minutes after taking a nitroglycerin sublingual tablet, Ms. R says that the
chest pressure is “almost gone.” Which action should the nurse take next?
1. Proceed with assessing her and completing the admission documentation.
2. Have her rest for another 5 minutes and then reassess the chest pressure.
3. Check her blood pressure and administer another nitroglycerin tablet.
4. Call the HCP, anticipating an order to readmit her to the hospital.
Ans: 3 National guidelines for patients with coronary artery disease indicate
that, if the chest pain is improving after nitroglycerin administration, giving
another nitroglycerin tablet is the first action to take. Completing the
admission assessment, having her rest, and notifying the HCP about her chest
pain are also appropriate actions, but administration of another nitroglycerin
tablet and resolution of the chest discomfort are the priorities. Focus:
Prioritization.
After taking a second nitroglycerin tablet, Ms. R says that the chest pressure and
shortness of breath are completely gone, and the nurse proceeds with the admission
assessment. Ms. R lives alone, but her daughter lives nearby and is with Ms. R today.
Ms. R’s blood pressure is 126/72 mm Hg, pulse is 82 beats/min, and respirations are
20 breaths/min. She has felt chest pressure twice since her discharge yesterday but
says, “I just waited and it went away after an hour or so.” She has not been taking her
prescribed medications because “I can’t remember which ones I have taken, and I don’t
want to take an overdose.” She has many questions about her medications, which
include:
• Nitroglycerin 0.4 mg sublingually as needed for chest pain
• Transdermal nitroglycerin 0.2 mg/hr every morning
• Metoprolol succinate 25 mg PO daily
• Clopidogrel 75 mg PO daily
• Aspirin 81 mg PO daily
• Enalapril 2.5 mg PO daily
10. Which action should the nurse take next?
1. Schedule the next home visit with the patient.
2. Assist the patient to take the prescribed medications.
3. Call the HCP to report the patient’s condition.
4. Remind the patient about the importance of medication compliance.
Ans: 2 Because the patient has not taken the prescribed medications to
control coronary artery disease and angina, the nurse’s first action will be to
ensure that the medications are taken. Scheduling the next home visit,
educating about the medications, and communicating with the HCP are all
appropriate but can be done later in the visit. Focus: Prioritization; Test
Taking Tip: In taking a test, carefully read all information that is supplied. If
you missed this answer, go back and read the information that precedes the
question and the answer will be clear.
Which activities in the patient’s care plan will the nurse delegate to a home
health aide? Select all that apply.
1. Setting up Ms. R’s medications in a multidose pill box twice a week
2. Instructing the daughter how to set up Ms. R’s daily medications
3. Teaching Ms. R and her daughter the purpose of each medication
4. Assisting Ms. R with a bath and personal hygiene every day
5. Measuring vital signs daily
6. Weighing the patient daily
7. Checking for any peripheral edema weekly
Ans: 4, 5, 6 Home health aide education and scope of practice include
assisting with personal hygiene and obtaining routine data such as vital sign
values and daily weights. It is the RN’s responsibility to evaluate these data
and plan individualized care using the data. Assessments, medication
preparation, and patient teaching about medications require more education
and broader scope of practice and should be performed by the RN. Focus:
Delegation.
When will the nurse schedule the next home visit with Ms. R?
1. Later today because Ms. R’s condition is very unstable and she may require
hospital readmission
2. Tomorrow because Ms. R’s assessment indicates that she needs frequent
evaluation or interventions
3. In 3 days because the home health aide will see Ms. R every day and will
call if there are any further problems
4. Early next week so that there will be enough time to evaluate the effect of
the medications on Ms. R’s symptoms
Ans: 2 The focus in home health nursing is empowering the patient and
family members by teaching self-care. Ms. R’s condition is not so unstable
that she needs to be reassessed today because her chest pain did resolve after
she took two nitroglycerin tablets, she has taken her medications, and her
daughter will be available. The patient’s symptoms of chest discomfort and
confusion about how to take her medications do indicate a need for
reassessment the next day. Although the home health aide will visit, the
education and role of the home health aide do not include evaluating the
patient’s response to prescribed therapies and planning changes in care based
on the evaluation. Focus: Prioritization.
- The nurse still has visits to make to Mr. D and Mr. I before the mandatory in-
service session. Which patient should be visited first? - Mr. D, who has diabetes and has an elevated glucose and fever
- Mr. I, who has lung cancer and is receiving chemotherapy
Ans: 2 Because Mr. I is in the nadir period after his chemotherapy, he is at
high risk for infection. Avoidance of any cross-contamination from Mr. D’s
leg infection is essential. Focus: Prioritization.
While driving to the next home visit, the nurse receives a telephone call from the home
health manager about a newly referred 70-year-old patient with emphysema who will
need an initial visit today to evaluate the need for home oxygen therapy.
14. Which staff member will the nurse suggest as the best person to make the
initial home visit for this new patient?
1. An experienced and knowledgeable LPN/LVN who has worked for 10
years in home health
2. A respiratory therapist who regularly works with patients who are
receiving home oxygen therapy
3. An RN who usually works in the maternal-child division of the public
health agency
4. An on-call RN who works in the home health agency for a few days each
month on an as-needed basis
Ans: 4 The initial assessment and development of the plan of care, including
interventions such as oxygen therapy, are the responsibility of RN staff
members. The RN with the most experience in caring for patients with
emphysema is the on-call part-time RN. Some patient care activities are
assigned to staff members from other disciplines, such as LPN/LVNs and
respiratory therapists, after the plan of care is developed by the RN. Focus:
Assignment.
When the nurse arrives at Mr. I’s condominium, his wife says that Mr. I is
very lethargic and a little confused today. Usually he is well oriented and
cheerful despite his diagnosis of right-sided lung cancer. Which information
noted during the assessment is the best indicator that rapid nursing action is
needed?
1. Breath sounds are decreased on the right posterior chest.
2. Mr. I says that his appetite has not been very good recently.
3. Mr. I’s oral temperature is 101°F (38.3°C).
4. The oral mucosa is pale and dry.
Ans: 3 Chemotherapy decreases the patient’s ability to mount a fever in
response to infection, so even a minor increase in temperature (especially in
combination with symptoms such as lethargy and confusion) can be an
indicator of a serious infection, including sepsis. The decreased right-sided
breath sounds are consistent with the patient’s diagnosis of lung cancer. The
poor appetite and dry oral mucous membranes also require assessment and
intervention, but infection is one of the most serious complications of
chemotherapy. Focus: Prioritization.
