Age-Related Risks HESI Case Study
How many mL of fluid should the client drink per day? - At least 30 mL/kg - At least 1500 mL/day - Mr. Rogers weighs 226 lbs (102.7 kg)
3081
(With the following information,) the nurse sets the insulin drip to deliver how many mL/hr? - Mr. Rogers weighs 226 lbs (102.7 kg) - His blood glucose is 312 mg/dL - Insulin drip is pre-mixed 100 units per 100 mL NS - Insulin infusion protocol (for CBG 300-329) = 4
4
Which recommendation by the nurse may help improve mild symptoms of BPH during the "watchful waiting" period?
Avoid sources of caffeine.
Which response by the client if of most concern to the nurse?
"My urine had a foul smell this morning."
Which of the following statements made by Mr. Rogers indicates the need for further teaching (regarding the medication doxazosin)?
"This medication may cause a rise in my blood pressure."
When using an 8-ounce drinking glass, the client should drink how many glasses per day to ingest 3081 mL in 1 day? 30 mL = 1 ounce
13
The pharmacist delivers dose of ampicillin in a 100mL bag of NS. In order to deliver the medication over 30 minutes, the nurse sets the pump to deliver how many mL/hr?
200
Which results of the dipstick urinalysis does the RN recognize as abnormal?
A. +1 Ketones. D. Trace leukocytes. E. Scant sediment.
The nurse considers which pharmacological age-related principles when administering medications or monitoring the effects of medications in the elderly client?
A. Dehydration can decrease the half-life of drugs. C. Drugs administered intravenously have a faster absorption rate than oral drugs. E.. Decreased cardiac output increases the risk for adverse drug reactions.
Along with clinical manifestations, which common laboratory findings indicate dehydration?
A. Elevated hemoglobin and hematocrit. B. Increased serum glucose. C. Increased serum osmolarity. E. Increased urine specific gravity.
Which of the following objective signs indicate dehydration?
A. Heart rate greater than 100 bpm. B. High creatinine levels. D. Postural hypotension.
What conditions, other than hyperglycemia, might Mr. Rogers have?
A. Osmotic diuresis. B. Glycosuria. C. Ketonuria.
In addition to the insulin, which of the following immediate measures would be indicated in the treatment of Mr. Rogers?
A. Potassium supplements. C. Sodium bicarb. E. 0.9% normal saline.
The nurse understand that which symptoms are commonly associated with BPH?
A. Straining while urinating. B. Frequent stopping and starting of urinary stream. C. Bladder distention. E. Dribbling at the end of urination.
With the understanding that Mr. Rogers' eating habits lack consistency, which physiological facts about the client's nutrition are most concerning to the nurse?
A. The development of hypoglycemia could be life-threatening. B. The stage II non-healing ulcer on the client's right heel could require amputation. C. Lack of appetite and not wanting to eat alone could lead to malnutrition. E. Dehydration exacerbated by lack of nutrition.
Which actions will help to maintain skin integrity?
A. Use heel protectors. C. Use special mattress or foot cradles. D. Apply skin moisturizers to prevent cracking. E. Instruct the client to wear clean white socks.
Which antimicrobial medications are safe alternatives for clients with penicillin allergies?
A. Vancomycin B. Erythromycin E. Clindamycin
Which lab value needs to be reported immediately?
Arterial pH 7.05
Which other symptoms should the nurse expect to find in a client with a diagnosis of diabetic retinopathy?
B. Loss of vision. C. Difficulty with color perception. D. Reports of floaters.
The nurse understands that which symptoms are associated with diabetic peripheral neuropathy?
B. Reduced ability to feel pain or temperature in the extremities. D. Problems with erectile dysfunction. E. Extreme sensitivity to touch.
Which teaching points should be included (for a nursing diagnosis of knowledge deficit related to signs and symptoms of hypoglycemia)?
C. Report excessive hunger and/or weakness. D. Report cold and clammy skin. E. Notify the HCP if there is headache or irritability.
Which data is most important to report to the HCP (when assessing for signs of nutritional problems)?
Dyspnea. (can be indicative of anemia)
The nurse understands that which information is correct regarding the prescribed insulin?
Glargine (Lantus) does not have a peak interval.
Which lab finding is of most concern to the nurse?
Hemoglobin 11.2 g/dL
Prior to changing the dressing on Mr. Rogers' right heel ulcer, the nurse should first take which actions?
Inspect the feet carefully for temp, sensation, and drainage.
The nurse anticipates that the client will receive which treatment for pernicious anemia?
Intramuscular injection of vitamin B-12.
Which (lab) results can affect drug distribution and influence drug-to-drug interactions?
Low serum albumin levels. (Can affect binding of drugs causing toxic effects, especially in elderly.)
Which information about the client is of most concern to the nurse?
Reports a new onset of blurry vision.
Which (possible EKG) pattern should the nurse report immediately to the HCP?
ST depression and "U" waves (Indicates hypokalemia)
It is important for the client to report which potential adverse or side effect associated with gabapentin (Neurontin)?
Tarry stool.
The nurse understands that which concept is important when addressing the client's physiological and psychosocial needs?
The client's diabetes mellitus should not present a problem for community dining.
The nurse understands that which physiological age-related change is often responsible for dehydration in the elderly?
Thirst decreases, contributing to less fluid intake.
Which technique is correct (for first dose of intramuscular B-12)?
Use a 1-1.5 inch needle.
Which instruction related to bath safety is best?
Use a bath thermometer to ensure that the temp is below 102F.
The nurse should instruct the client to take which action first when collecting a urine sample?
Wipe the genital area clean.
