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A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? Select all.
- A. Older adults are more prone to dehydration than younger adults.
- B. Older adults need the same amount of most vitamins and minerals as younger adults.
- C. Many older men and women need calcium supplementation.
- D. Older adults need more calories than they did when they were younger.
- E. Older adults should consume a diet low in carbohydrates.
Correct Answer: A, B, C
Rationale: The correct answer is A, B, and C.
A: Older adults are more prone to dehydration due to age-related physiological changes that decrease the body's ability to conserve water.
B: While older adults generally need the same amount of vitamins and minerals as younger adults, they may require higher amounts of certain nutrients like vitamin D and calcium.
C: Many older men and women may need calcium supplementation to prevent osteoporosis and maintain bone health.
Incorrect choices:
D: Older adults typically need fewer calories as they age due to decreased metabolism and physical activity.
E: There is no specific recommendation for older adults to consume a diet low in carbohydrates, as carbohydrates are an essential energy source.
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A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
- A. Increase the oxygen flow.
- B. Assist the client to Fowler's position.
- C. Promote removal of pulmonary secretions.
- D. Obtain a specimen for arterial blood gases.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to Fowler's position. This is the priority intervention because elevating the client to Fowler's position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and allowing better ventilation. Increasing oxygen flow (Choice A) may be needed, but positioning takes precedence. Promoting removal of pulmonary secretions (Choice C) is important but not the priority in this case. Obtaining arterial blood gases (Choice D) is important for assessing oxygenation status but can be done after ensuring optimal positioning.
A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique?
- A. I will straighten my ear canal by pulling my ear down & back.
- B. I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops.
- C. I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in.
- D. After the drops are in, I will place a cotton ball all the way into my ear canal.
Correct Answer: B
Rationale: The correct answer is B: "I will gently apply pressure with my finger to the tragus of my ear after putting in the drops." This statement indicates understanding of the proper technique because applying pressure to the tragus helps the ear drops to reach the ear canal. The tragus is a small cartilaginous projection in front of the ear canal that, when pressed, helps to facilitate the passage of the drops into the ear. This action ensures proper distribution of the medication for effective treatment.
Other choices are incorrect:
A: Pulling the ear down and back is a technique used for administering ear drops in children, not adults.
C: Inserting the nozzle snug into the ear can cause injury to the ear canal and eardrum.
D: Placing a cotton ball all the way into the ear canal can prevent the drops from reaching the ear canal and may cause blockage.
A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the client asks why water is necessary after the formula drains, the nurse should respond:
- A. Water helps clear the tube so it doesn't get clogged.
- B. Flushing helps make sure the tube stays in place.
- C. This will help you get enough fluids.
- D. Adding water makes the formula less concentrated.
Correct Answer: A
Rationale: The correct answer is A: Water helps clear the tube so it doesn't get clogged. Water is necessary after enteral feeding to flush the feeding tube and prevent clogging, ensuring proper delivery of nutrition. Flushing with water also prevents residue buildup and maintains tube patency. This action helps prevent complications such as tube occlusion, which can lead to inadequate delivery of feedings or discomfort for the client. Options B, C, and D are incorrect because the primary reason for flushing the tube with water is to prevent clogging and maintain tube patency, not to secure the tube, provide fluids, or adjust formula concentration.
A nurse is caring for a client who is receiving continuous enteral feedings. What is the highest priority intervention when the nurse suspects aspiration?
- A. Auscultate breath sounds.
- B. Stop the feeding.
- C. Obtain a chest x-ray.
- D. Initiate oxygen therapy.
Correct Answer: B
Rationale: The correct answer is B: Stop the feeding. Aspiration can lead to serious complications such as pneumonia. Stopping the feeding immediately is crucial to prevent further aspiration and minimize harm to the client. Auscultating breath sounds (choice A) is important but should be done after stopping the feeding. Obtaining a chest x-ray (choice C) may be necessary later for further evaluation but is not the highest priority in this situation. Initiating oxygen therapy (choice D) may be needed depending on the client's condition, but it is not the highest priority when aspiration is suspected.
A nurse is preparing to administer digoxin (Lanoxin) to a client who states, 'I don't want to take that med. I do not want one more pill.' Which of the following responses by the nurse is appropriate in this situation?
- A. Your physician prescribed it for you, so you really should take it.
- B. Well, let's just get it over with quickly then.
- C. Okay, I'll just give you your other meds.
- D. Tell me your concerns with taking this med.
Correct Answer: D
Rationale: Correct Answer: D. Tell me your concerns with taking this med.
Rationale: This response demonstrates therapeutic communication by acknowledging the client's feelings and encourages them to express their concerns. It shows empathy and respect for the client's autonomy in decision-making. By understanding the client's reasons for not wanting to take the medication, the nurse can address any misconceptions, provide education, and potentially find alternative solutions. This approach fosters trust and collaboration between the nurse and the client.
Incorrect choices:
A: This response is dismissive of the client's feelings and does not address the underlying concerns.
B: This response does not address the client's reluctance and may come off as insensitive.
C: This response avoids the issue at hand and does not promote open communication.