Health Care of the Older Adult NCLEX

Health Care of the Older Adult NCLEX Related

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The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 4 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.

For each possible intervention, click to specify if the intervention is essential or contraindicated.

  • A. Seizure precautions
  • B. Request a prescription for dextrose 5% in water (D5W)
  • C. Measure axillary temperature frequently
  • D. Apply a cooling blanket
  • E. Encourage the client to consume cool liquids
  • F. Establish continuous cardiac monitoring
  • G. Insert an indwelling urinary drainage catheter
Correct Answer: A,B,C,D,E,F,G

Rationale: A (Essential), B (Contraindicated), C (Contraindicated), D (Essential), E (Contraindicated), F (Essential), G (Essential). Seizure precautions, cooling blanket, cardiac monitoring, antipyretics, catheter, and clothing removal are essential for heat stroke management. D5W risks fluid overload, axillary temperature is unreliable, and oral fluids are unsafe due to altered mental status.

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The nurse is taking care of a client with Clostridium difficile (C. difficile). The nurse should do which of the following to prevent the spread of infection? Select all that apply.

  • A. Wear a particulate respirator.
  • B. Wear sterile gloves when providing care.
  • C. Cleanse hands with alcohol-based hand sanitizer.
  • D. Wash hands with soap and water.
  • E. Wear a protective gown when in the client's room.
Correct Answer: D,E

Rationale: To prevent the spread of C. difficile, washing hands with soap and water (D) is essential as alcohol-based sanitizers are ineffective against its spores, and wearing a protective gown (E) prevents contamination. A respirator (A) is unnecessary, sterile gloves (B) are not required (clean gloves suffice), and alcohol sanitizer (C) is ineffective. CN: Safety and infection control; CL: Create

The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?

  • A. The client's daily record indicates a 3 kg weight loss in 2 days.
  • B. The client is complaining of nausea.
  • C. The client has a temperature of 99°F orally.
  • D. The client has fatigue.
Correct Answer: A

Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or dehydration, requiring urgent attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical symptoms.

During cardiopulmonary resuscitation (CPR), the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for injury with compression over the xiphoid process?

  • A. Lung.
  • B. Liver.
  • C. Stomach.
  • D. Diaphragm.
Correct Answer: B

Rationale: Compressing the xiphoid process risks liver injury, as it lies directly beneath, potentially causing laceration or hemorrhage.

The client is receiving an I.V. infusion of 5% dextrose in normal saline running at 125 mL/hour. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first:

  • A. Discontinue the infusion.
  • B. Apply a warm soak to the site.
  • C. Stop the flow of solution temporarily.
  • D. Irrigate the needle with normal saline.
Correct Answer: A

Rationale: Swelling and hardness indicate infiltration, requiring immediate discontinuation of the infusion to prevent tissue damage.

The nurse is developing a care plan with a client who had a laryngectomy 3 days ago. The nurse should instruct the client to do which of the following to assure adequate nutrition. Select all that apply.

  • A. Weigh weekly and report weight loss.
  • B. When eating, sit and lean slightly forward.
  • C. Have serum albumin level checked regularly.
  • D. Administer enteral tube feedings as ordered.
  • E. Manipulate the nasogastric tube daily.
Correct Answer: A,B,C,D

Rationale: To ensure adequate nutrition post-laryngectomy, the client should monitor weight, sit and lean forward to aid swallowing, check serum albumin for nutritional status, and use enteral feedings as ordered. Manipulating the tube is not recommended to avoid dislodgement.

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