Nokea
An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia?
- A. Advanced age
- B. Environmental exposure
- C. Nutritional deficit
- D. Obesity
Correct Answer: A
Rationale: Advanced age (85 years) is the greatest risk factor for pneumonia due to weakened immune response and comorbidities. Other factors are less significant.
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The client has a prolonged prothrombin time. What question is important to ask the client when interpreting this information?
- A. How often do you eat meat?
- B. How much alcohol do you drink?
- C. Do you take heparin?
- D. Have you had a recent injury?
Correct Answer: B
Rationale: Excessive alcohol consumption can impair liver function, prolonging prothrombin time by reducing clotting factor production, a key question to assess.
The nurse is caring for a client who has type 2 diabetes mellitus and an elevated hemoglobin A1c. Which statement by the nurse will best address this result?
- A. It is important for us to review the signs and symptoms of a hypoglycemic reaction.
- B. Let's review your diet, exercise, and medication regimen over the past 2-3 months.
- C. Please describe what you have eaten in the last 24-48 hours.
- D. You should fast for at least 8 hours prior to your morning blood work.
Correct Answer: B
Rationale: Elevated A1c reflects poor glycemic control over months, so reviewing diet, exercise, and medications is most relevant. Other options are less comprehensive.
The nurse is attending an end-of-year school family picnic. Which situation needs an immediate intervention?
- A. A 2-year-old eating a hot dog unsupervised
- B. A 3-year-old playing alone in a wading pool
- C. A 4-year-old tossing a beach ball
- D. A 5-year-old climbing on monkey bars
Correct Answer: B
Rationale: A 3-year-old alone in a wading pool is at immediate risk of drowning, requiring urgent intervention. A poses a choking risk but is less immediately life-threatening. C and D are age-appropriate activities with lower immediate risk.
An adult is to have a cardiac catheterization performed tomorrow. When preparing the client for the cardiac catheterization, it is essential for the nurse to do which of the following?
- A. Administer an enema two hours before the procedure
- B. Limit caffeine the day before the procedure
- C. Ask the client about allergies to shellfish
- D. Restrict fat intake the day before the procedure
Correct Answer: C
Rationale: Shellfish allergies may indicate iodine sensitivity, critical for contrast dye used in cardiac catheterization.
The nurse is reinforcing teaching with the parents of a 6-year-old client who is experiencing fecal incontinence related to functional constipation. Which of the following information should the nurse reinforce? Select all that apply.
- A. Instruct your child to sit on the toilet for 30 minutes after each meal.
- B. Use a reward system, such as a sticker chart, to encourage your child.
- C. Provide your child with a foot stool to rest the feet on while sitting on the toilet.
- D. Encourage your child to increase the intake of fluids throughout the day to soften the stool.
- E. Keep a record of your child's bowel movements, laxative use, and episodes of incontinence
Correct Answer: B,C,D,E
Rationale: Reward systems, foot stools, increased fluids, and tracking bowel movements aid in managing constipation. Sitting for 30 minutes is excessive and impractical.