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A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?
- A. Confusion.
- B. Urinary retention.
- C. Incontinence.
- D. Low back pain.
Correct Answer: A
Rationale: Confusion is a unique symptom of urinary tract infections (UTIs) in older adults, often being the first or only symptom, making it a critical indicator for this age group.
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A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22, PaCO₂ 68 mm Hg, Base excess -2, PaO₂ 78 mm Hg, Oxygen saturation 80%, Bicarbonate 28 mEq/L. Which of the following interpretations of the ABG values should the nurse make?
- A. Respiratory alkalosis.
- B. Respiratory acidosis.
- C. Metabolic acidosis.
- D. Metabolic alkalosis.
Correct Answer: B
Rationale: Low pH (7.22) and high PaCO₂ (68 mm Hg) indicate respiratory acidosis, caused by CO₂ accumulation due to inadequate ventilation.
A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease (GERD) about minimizing the effects of reflux during sleep. Which of the following client statements indicates an understanding of the teaching?
- A. I can have 6 ounces of alcohol before bed to help me sleep.
- B. I will have a snack 1 hour before going to bed.
- C. I should elevate the head of the bed.
- D. I will sleep on my stomach with my head flat.
Correct Answer: C
Rationale: Elevating the head of the bed helps reduce acid reflux by keeping stomach acid from flowing back into the esophagus during sleep.
A nurse is contributing to the plan of care for an older adult client who has a WBC of 2000/mm³ after three rounds of chemotherapy. Which of the following interventions should the nurse include in the plan?
- A. Serve cooked fruit with meals.
- B. Report temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours.
- C. Place the client in a room with negative-pressure airflow.
- D. Instruct client to use an incentive spirometer every 4 hours.
Correct Answer: A
Rationale: Serving cooked fruit reduces infection risk by eliminating pathogens, appropriate for a client with low WBC counts.
A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching?
- A. You should wear glasses instead of contacts while taking this medication.
- B. A yellow tint to the skin is an expected reaction to the medication.
- C. Lifelong treatment with this medication is necessary.
- D. The medication causes amenorrhea if taken along with an oral contraceptive.
Correct Answer: A
Rationale: Rifampin can cause discoloration of body fluids, including tears, which can stain contact lenses. Therefore, it is recommended to wear glasses instead of contacts while taking this medication.
A nurse is preparing to administer hydrochlorothiazide 25 mg PO. The amount available is hydrochlorothiazide 50 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. (Do not use a trailing zero))
Correct Answer: 1 tablet
Rationale: 25 mg ÷ 50 mg/tablet = 0.5 tablets, but since tablets cannot be split without specific instructions, the nurse should administer 1 tablet as per standard practice.