Nokea
The old-old population (85 years and older) has an increased risk for frailty. However, old age is just one element of frailty. Identify at least three other assessment findings that contribute to frailty.
- A. Decreased muscle mass
- B. Weight loss
- C. Reduced physical activity
- D. Increasing disability and symptoms
Correct Answer: A
Rationale: Decreased muscle mass, unintentional weight loss, and reduced physical activity are key contributors to frailty in older adults.
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A client is admitted to the unit for chemotherapy. To prevent an acid-base problem, which of the following would you instruct the nursing assistant to report?
- A. Repeated episodes of nausea and vomiting
- B. Complaints of pain associated with exertion
- C. Failure to eat all food on breakfast tray
- D. Client hair loss during morning bath
Correct Answer: A
Rationale: Nausea and vomiting can lead to metabolic alkalosis due to loss of gastric acid, making it important to report promptly to prevent acid-base imbalances.
The patient asks when she should take bisphosphonate medications for treatment of osteoporosis. You tell her
- A. On a full stomach.
- B. Just before getting into bed.
- C. First thing in the morning on an empty stomach with a full glass of water, 30 to 60 minutes before eating, and without lying down.
- D. With an acidic liquid such as orange juice.
Correct Answer: C
Rationale: Bisphosphonates require specific administration guidelines to enhance absorption.
What observation would indicate the water-seal drainage system is working correctly?
- A. No bubbling of air in the suction control bottle
- B. Fluctuation of the fluid level in the tube of the water-seal bottle
- C. 25 ml of serosanguineous fluid has collected in the drainage bottle
- D. Excessive bubbling in the water-seal bottle
Correct Answer: B
Rationale: Fluctuation indicates proper lung expansion and absence of leaks.
The nurse is reviewing the laboratory results for a preoperative patient. Which test result should be brought to the attention of the surgeon immediately?
- A. Serum K+ of 3.8 mEq/L
- B. Hemoglobin of 15 g/dL
- C. Blood glucose of 100 mg/dL
- D. White blood cell (WBC) count of 18,500/µL
Correct Answer: D
Rationale: An elevated WBC count indicates potential infection, requiring immediate attention.
Which statement by a patient with diabetes indicates an understanding of the medication insulin glargine injection (Lantus)?
- A. Lantus causes weight loss.
- B. Lantus is used only at night.
- C. The duration of Lantus is six hours.
- D. There is no peak time for Lantus.
Correct Answer: D
Rationale: Lantus is a long-acting insulin with no distinct peak action.