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The nurse is developing a care plan for an older client being admitted to a long-term care facility. Which information should the nurse use to plan interventions for this client? Select all that apply.
- A. Older clients tend to be incontinent.
- B. Older clients are at risk for dehydration.
- C. Depression is a normal part of the aging process.
- D. Age-related skin changes require special monitoring.
- E. Older clients are at risk for complications of immobility.
- F. Confusion and cognitive changes are common findings in the older population.
Correct Answer: B,D,E
Rationale: Older clients are at risk for dehydration and complications related to immobility. Another normal physiological change that occurs during the aging process is loss of skin integrity. Incontinence, depression, confusion, and cognitive changes are not normal parts of the aging process.
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A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation?
- A. Weight loss
- B. Bilateral crackles
- C. Distended neck veins
- D. Peripheral pitting edema
Correct Answer: B
Rationale: The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure.
The nurse assists a client diagnosed with a renal disorder in collecting a 24-hour urine specimen. Which intervention does the nurse implement to ensure proper collection of the 24-hour urine specimen?
- A. Have the client void at the start time and discard the specimen.
- B. Strain the specimen before pouring the urine into the container.
- C. Save all urine, beginning with the urine voided at the start time.
- D. Once completed, refrigerate the urine collection until picked up by the laboratory.
Correct Answer: A
Rationale: The nurse asks the client to void at the beginning of the collection period and discards this urine sample because this urine has been stored in the bladder for an undetermined length of time. All urine thereafter is saved in an iced or refrigerated container. The client is asked to void at the finish time, and this sample is the last specimen added to the collection.
A client experiencing difficulty breathing and increased pulmonary congestion was prescribed furosemide 40 mg to be given intravenously. After an hour which assessment value indicates that the therapy has been effective?
- A. The lungs are now clear upon auscultation.
- B. The urine output has increased by 400 mL.
- C. The blood pressure has decreased from 118/64 mm Hg to 106/62 mm Hg.
- D. The serum potassium has decreased from 4.7 mEq to 4.1 mEq (4.7 mmol/L to 4.1 mmol/L).
Correct Answer: A
Rationale: Furosemide is a diuretic. In this situation, it was given to decrease preload and reduce the pulmonary congestion and associated difficulty in breathing. Although all options may occur, option 1 is the reason that the furosemide was administered.
A client who underwent surgical repair of an abdominal aortic aneurysm is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. What action should the nurse take?
- A. Start the client on sips of water.
- B. Remove the nasogastric (NG) tube.
- C. Call the primary health care provider immediately.
- D. Document the finding and continue to assess for bowel sounds.
Correct Answer: D
Rationale: Bowel sounds may be absent for 3 to 4 postoperative days because of bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube should stay in place if present, and the client is kept NPO until after the onset of bowel sounds. Additionally, the nurse does not remove the tube without a prescription to do so. There is no need to call the primary health care provider immediately at this time.
The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition?
- A. Do you have tremors in your hands?
- B. Are you experiencing pain in your joints?
- C. Have you had problems with diarrhea lately?
- D. Do you notice any swelling in your legs at night?
Correct Answer: B
Rationale: Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological fractures. Options 1 and 3 relate to assessment of hypoparathyroidism. Option 4 is unrelated to hyperparathyroidism.