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A nurse is assisting a client in planning an exercise routine. Which of the following activities should the nurse encourage the client to avoid due to age-related changes?
- A. Stretching
- B. Running
- C. Resistance training
- D. Aerobic exercises
Correct Answer: B
Rationale: The correct answer is B: Running. Age-related changes such as decreased bone density and joint stiffness can make running high-impact and potentially harmful. Stretching (A) is important for flexibility, resistance training (C) helps maintain muscle mass, and aerobic exercises (D) improve cardiovascular health. Running may exacerbate joint issues.
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A nurse is collecting data from a client who is receiving intermittent enteral feedings. Which of the following laboratory values should the nurse identify as an indication that the client needs a change in the formula?
- A. Hematocrit 42%
- B. Urine specific gravity 1.022
- C. BUN 28 mg/dL
- D. Sodium 142 mEq/L
Correct Answer: C
Rationale: The correct answer is C: BUN 28 mg/dL. An elevated BUN level indicates poor protein metabolism, which could be a sign that the current enteral formula is not being adequately utilized by the client. This could lead to malnutrition or other complications.
A: Hematocrit measures the volume percentage of red blood cells in blood. It is not directly related to enteral feedings.
B: Urine specific gravity reflects hydration status and kidney function, not related to enteral feedings.
D: Sodium level is not specific to enteral feedings.
In summary, an elevated BUN level signifies poor protein metabolism and indicates a need for a change in the enteral formula to better meet the client's nutritional needs.
A nurse identifies an extravasation of a vesicant solution at a client's peripheral IV catheter's insertion site. Identify the sequence in which the nurse should perform the following actions.
- A. Aspirate the solution from the catheter.
- B. Stop the infusion.
- C. Disconnect the tubing from the catheter.
- D. Remove the IV catheter.
- E. Attach a syringe to the catheter.
Correct Answer: B,E,A,C,D
Rationale: The correct sequence is B, E, A, C, D. First, stopping the infusion prevents further harm. Then, attaching a syringe helps to aspirate the vesicant solution. Aspirating the solution reduces tissue damage. Disconnecting the tubing prevents further exposure. Lastly, removing the IV catheter minimizes harm and promotes healing. Incorrect choices: A is incorrect as the solution should be aspirated after stopping the infusion. C is incorrect as disconnecting the tubing should come after aspirating the solution. D is incorrect as removing the IV catheter is the final step after all the previous actions have been completed.
A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?
- A. To regulate blood pressure
- B. To promote digestion
- C. To enhance the immune system
- D. To reduce inflammation
Correct Answer: B
Rationale: The correct answer is B: To promote digestion. Ginger tea is commonly used in Chinese culture to aid digestion and alleviate gastrointestinal issues, making it a suitable choice for a client recovering from a bowel obstruction. Ginger has natural properties that can help stimulate digestive enzymes and improve digestion. This can be beneficial for the client to ease any potential digestive discomfort after the bowel obstruction.
Other choices are incorrect because:
A: Ginger tea is not typically used to regulate blood pressure.
C: While ginger can have some immune-boosting properties, the primary purpose in this scenario is related to digestion.
D: Ginger does have anti-inflammatory properties, but the client's request for ginger tea is more likely for digestive purposes.
A nurse is caring for an older adult client who has dementia and wanders at night. Which of the following interventions should the nurse take?
- A. Assign the client to a quiet room away from the nurses' station.
- B. Elevate the four side rails on the client's bed at night time.
- C. Encourage the client to rest during the day.
- D. Take the client to the bathroom on a regular schedule.
Correct Answer: D
Rationale: The correct answer is D: Take the client to the bathroom on a regular schedule. This intervention helps reduce the risk of falls and incontinence by ensuring the client's regular toileting needs are met. It also helps maintain the client's dignity and comfort. Assigning the client to a quiet room away from the nurses' station (A) may increase feelings of isolation and anxiety. Elevating all four side rails on the bed (B) can be considered a restraint and is not recommended as a first-line intervention. Encouraging the client to rest during the day (C) may disrupt the client's circadian rhythm and worsen nighttime wandering.
A nurse is reviewing the medical record for a client who has pneumonia. The nurse should plan to have the client lie on his back with his head lower than his feet to mobilize secretions from which of the following lung segments?
- A. Apical segments
- B. Both upper lobes
- C. Anterior segments of both lower lobes
- D. Posterior segments of both lower lobes
Correct Answer: C
Rationale: Trendelenburg position assists in draining secretions from the anterior lower lung segments.