Passpoint 1 Older Adult

Which is not a risk factor for the development of atherosclerosis?

late onset of puberty

The correct landmark for obtaining an apical pulse is the:

left fifth intercostal space, midclavicular line.

A client is taking metoprolol and hydrochlorothiazide. The medication is effective if it:

lowers the blood pressure.

What instruction should the nurse's discharge teaching plan for the client with heart failure include?

obtaining daily weights at the same time each day

A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to:

reduce the chance of blood clot formation.

The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown? A person who has:

reduced sensation of pressure.

The health care provider has prescribed penicillin for a client admitted to the hospital for treatment of pneumonia. Prior to administering the first dose of penicillin, the nurse should ask the client:

"Have you had a previous allergy to penicillin?"

The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot, followed by an infection. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse?

"I will take the antibiotics until the redness goes away and my foot feels better."

A client is admitted to a health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

Impaired gas exchange related to airflow obstruction

The client is to receive digoxin 0.25 mg. Available are 0.125-mg scored tablets. How many tablets should the nurse administer?

2 tablets

When instructing clients on how to decrease the risk of chronic obstructive pulmonary disease (COPD), the nurse should emphasize which instruction?

Abstain from cigarette smoking.

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?

Leg edema

A client with bronchitis is ordered 300 mg of liquid guaifenesin every 4 hours. The container indicates that there is 200 mg/5 mL. How many milliliters should the nurse administer per dose? Record your answer using one decimal place.

7.5

A client with chronic obstructive pulmonary disease (COPD) has developed tachypnea, dyspnea, and oxygen saturation (SaO2) of 90%. Which of the following actions by the nurse is most appropriate?

Assist the client to sit in a chair and lean slightly forward with hands on the knees

The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?

Asymmetry

The nurse is caring for an elderly, debilitated client who has been bedridden for an extended period. Which sign or symptom indicates that the client has hypoxia?

Confusion

A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?

Low serum potassium level

A nurse records a client's history and discovers several risk factors for coronary artery disease (CAD). Which cardiac risk factors can the client control?

Diabetes, hypercholesterolemia, and hypertension

Which would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia?

Obtain influenza and pneumococcal vaccines.

A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza?

Pneumonia

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?

Use of accessory muscles

A nurse is caring for a cardiac client who requires various cardiac medications. When the nurse helps the client out of bed for breakfast, the client becomes dizzy and asks to lie down. The nurse helps the client lie down, puts up the side rails, and obtains the client's blood pressure, which is 84/50 mm Hg. It's time for the nurse to administer the client's medications: nitroglycerin, metoprolol, and furosemide. Which action by the nurse is best?

Withhold the medications and notify the physician.

A client with chronic heart failure is receiving digoxin, 0.25 mg by mouth daily, and furosemide, 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause:

visual disturbances.

The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is:

washing the hands frequently.

Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.