Nokea
A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)
- A. Increased peripheral circulation.
- B. Increased constipation.
- C. Decreased muscle mass.
- D. Decreased cough reflex.
Correct Answer: B,C,D
Rationale: B: Reduced motility causes constipation. C: Sarcopenia reduces muscle mass. D: Weaker cough reflex increases aspiration risk.
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A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Prevents skin breakdown. D: Ensures early detection of issues. E: Ensures proper fit and circulation.
A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?
- A. He appears anxious about the transfer.
- B. His partner has been visiting.
- C. He is voiding adequately.
- D. He is allergic to sulfa.
Correct Answer: D
Rationale: Allergy information is critical to prevent adverse reactions during care.
A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?
- A. Clean the hearing aid with isopropyl alcohol.
- B. Turn the hearing aid off for 5 minutes.
- C. Soak the hearing aid in warm water.
- D. Decrease the volume on the hearing aid.
Correct Answer: D
Rationale: Decreasing volume reduces feedback causing the whistling sound.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client receives burns from a heating pad.
- B. A client reports being dissatisfied with the temperature of the meals provided.
- C. A client becomes disoriented and falls out of bed.
- D. A client’s visitor becomes dizzy and faints in the client's room.
- E. A client is unable to afford the physical therapy that the provider recommends.
Correct Answer: A,C,D
Rationale: A: Injury requires reporting. C: Fall indicates safety issue. D: Visitor incident needs documentation.
A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which sequence should the nurse perform the following steps?
- A. Apply clean gloves.
- B. Disconnect the tube from the suction device.
- C. Instill 50 mL of air into the tube.
- D. Ask the client to take a deep breath.
- E. Pinch and withdraw the tube.
Correct Answer: A,B,C,D,E
Rationale: A: Gloves ensure hygiene. B: Disconnect suction. C: Air clears tube. D: Breath aids removal. E: Pinch prevents leakage.