ATI - Geriatics - Midterm
A nurse is caring for an older adult client who has dementia. The client's family member asks why the provider will not prescribe a medication to calm the client down. Which of the following statements should the nurse make?
"It can increase their risk of falls"
A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?
"It is a good idea to use the handrails in the bathroom"
A nurse in a clinic is providing education with an older adult client about Medicare. Which of the following statements by the client indicates an understanding?
"My prescriptions are covered under Part D"
A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching?
- I must stop smoking -I need to monitor my weight -I'm limiting my intake of fast foods
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion?
- More difficulty seeing due to a greater sensitivity to glare - Decreased cough reflex -Decreased bladder capacity - Dehydration of intervertebral disc
A nurse is assessing a client's wound dressing, and observes a water red drainage. The nurse should document this drainage as which of the following?
Serosanguineous
A nurse is monitoring an older adult female client who had a myocardial infarction for the development of an acute kidney injury. Which of the following findings should the nurse identify as indicating an increased risk of acute kidney injury?
Serum creatinine 1.8 mg/dL
A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take?
Serve cooked fruits with meals
A nurse is caring for a 44-year old client who was admitted with an elevated tempt and abdominal pain. Select the 5 client findings that require immediate follow-up
-Potassium 7.0 mEq/L -WBC count 17,000/mm3 -No dialysis for 24hr -Abdomen rigid with decreased bowel sounds -Crackles throughout lungs
A nurse is caring for a client who is to have IV urography. Which of the following is a contraindication to this procedure?
Allergy to shellfish
A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect?
Furrows in the tongue
A nurse is teaching about risk factors of developing a stroke to a group of older adults. Whats a non modifiable risk factor ?
Genetics
A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?
Grapefruit juice
A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect?
Hyperpigmentation
A nurse is caring for a client on the medical-surgical unit. Complete the diagram by dragging from the choices.
Hypocalcemia, Prepare serum albumin and initiate seizure precautions, Impaired memory, monitor bowel sounds
A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication the client might be experiencing a hemolytic reaction?
Hypotension
A nurse is reinforcing discharge instructions with a client following a laminectomy. Which of the following instructions should the nurse include?
Sit in straight-back chairs
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications?
Hypotension Absense of bowel sounds Weakened gag reflex
A nurse is developing an education program about skin cancer for a communnity center. Which of the following instructions should the nurse plan to include?
Keep a body map of skin lesions
A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take?
Keep blood pressure equipment in the client's room
A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders?
Kyphosis
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?
Kyphosis
A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include?
Manifestations of the virus are similar to flu-like symptoms
A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following values should the nurse select?
Median vein in the forearm
A nurse is caring for a client who has asthma and developed viral pharyngtis. Which of the following findings should the nurse expect?
Negative throat culture
A nurse in a clinic is caring for a client who has a new diagnosis of SLE. Drag words from the choices below to fill in each blank in the following sentence
The client is at risk for developing chronic fatigue and photosensitivity.
A nurse is performing chest physiotherapy on a client who has a respiratory infection. To increase the velocity andturbulence of the air the client exhales, which of the following techniques should the nurse use?
Vibration
A nurse is teaching a client who has a vitamin K deficiency about the effects of vitamin K. Which of the following information should the nurse include in the teaching?
Vitamin K reverse warfarin toxicity
A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for a knee arthroplasty. The nurse should notify the surgeon of which of the following results?
WBC count 20,000/mm3
A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse implement to ensure proper dialysate exchange?
Warm the dialysate solution prior to instillation
A nurse is caring for a client who will have blood sampling for a serum creatinine level and asks what this test shows. Which of the following responses should the nurse make?
"This test will tell your doctor how your kidneys are functioning."
A nurse is caring for an older adult client. The nurse should recognise the client is at risk for which of the following physiological changes?
-Decreased gastric mobility -Decreased skin elasticity -Increased pain threshold
A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client?
Cystitis
A nurse is caring for a client. Select the 3 findings that require an immediate follow-up.
HCT level Stools Emesis
A nurse is an emergency department is caring for a client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing?
Asthma, Monitor the client's pulmonary function tests and o2 stats, administer bronchodilator, measures the peak flo
A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles?
Autonomy
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following insturctions should the nurse include
Avoid lifting anything heavier than 4.5kg (10lb) for 1 week
A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include?
Clients should have a yearly test for fecal occult blood
A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
Code status
A nurse is teaching a class about medication reconcilation. Which of the following information should the nurse include in the teaching?
Provide a list of the client's current medications during admission to a health care facility.
A nurse is teaching a class about pain mangement in older adult clients. Which of the following information should the nurse include?
Older adult cleints frequently underreport pain
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Oral mucosa
A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestations of which of the following complications?
Postoperative delirium
A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?
Potassium 2.9 mEq/L
A nurse is caring for a client involved in a suspected bioterrorism event involving exposure to cutaneous anrthax. Which of the following manifestations should the nurse anticipate?
Skin lesions with pruitus
A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?
Small drops of clear fluid in the left ear
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider?
Sodium 126 mEq/L
A nurse is working with an older adult client who has been diagnosed with somatic symptom disorder. Which of the following should the nurse consider when working with an older adult who has somatic symptom disorder?
Somatic symptom disorder is usually underdiagnosed in the older populaiton
The nurse is caring for the client immediately following the insertion of the permanent pacemaker. Complete the following sentence by using the list of options.
Stroke and Bradycaria
A nurse enters an adult client's room and finds him unresponsive. After determining, that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first?
Summon the code team
A nurse is caring for an older adult who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?
Systolic blood pressure changed from 140 mm Hg to 120 mm Hg
A nurse is caring for an older adult client who as just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following should the nurse notify the provider?
Systolic blood pressure changeed from 140 mm to 120 mm
A nurse in a clinic is reviewing the lab values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following?
TSH - Thyroid stimulating hormone
A nurse is teaching a client who has acute kidney injury about dietary sources of potassium. Which of the following statements by the client indicates a need for clarification?
"Adding pecans will be a change I can readily make"
A nurse is providing instructions for a 52-year old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
"Before the examination, your provider will give you a sedative that will make you sleepy."
a nurse is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a training zero.)
0.4mL
A nurse is preparing to administer dexamesthesone 8 mg IM divided into 4 equal doses QID. Avaliable is 4mg/Ml, How many mL?
0.5 mL
A nurse is assessing a client who has a new diagnosis of systemic lupus erythematosus (SLE). Manifestations?
Butterfly rash on face
A nurse is assessing a client who has hypoparathyroidism. Which of the following findings should the nurse expect?
Client report of numbness in his hands
A nurse is preparing to administer furosemide 40 mg IV. Avaliable is furosemide 10mg/1 mL. How many mL should the nurse administer per dose?
4mL
A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?
Ability to sell-feed with the use of adaptive equipment
A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make?
Because of your surgery, you have an altered ability to smell and taste
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority
CD4-T-cell count 180 cells
A nurse is caring for an older adult client who has major depressive disorder. The client states "I don't think I am financially prepared for retirement, yet I am eligible to retire this year." The nurse should identify that the client is in which of the following stages of Erikson's stages of development?
Ego integerity vs. Despair
A nurse is caring for an older adult client who has a femoral head fracture 24 hours ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
Fat embolism
A nurse is preparing a teaching session about reducing the risk of complications of diabetes mellitus. Which of the following information should the nurse plan to include in the teaching?
Reduce cholesterol and saturated fat intake, increase physical activity and daily exercise, enroll in a smoking cessation program, maintain optimal blood pressure to prevent kidney damage
A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide to the client?
Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart
A nurse is in a clients room when the client begins having a tonic- clonic seizure. Which of the following actions should the nurse take first?
Turn the client's head to the side
A nurse is preparing to move a client who is only partially able to assist up in the bed. Which of the following methods should the nurse plan to use?
Two nurses using a friction-reducing device
A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?
urine output of 175 mL in the past 8 hr
A nurse is revieiwing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?
pH below 7.35
A home health nurse is assessing an older adult client who reports falling a couple times over the past week. Which of the following findings should the nurse suspect is contributing to the client's falls?
the client takes alprazolam
A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine?
"Chew on sugarless gym or suck on hard, sour candies"
A nurse is teaching a client who has a new prescription for disulfiram. Which of the following information should the nurse include in the teaching?
"Do not drink alcohol while taking this medication."
A nurse is teaching a client who is scheduled for a CT scan of the head with contrast. Which of the following statements by the client indicates a need for further teaching?
"I can take my morning dose of metformin"
A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication?
"I feel nauseted and have to appetite"
A nurse is reinforcing teaching with an older adult client who has major depressive disorder and a prescription for nortripyline 25mg daily. Which of the following client statements indicates understanding of the teaching?
"I should sit on the side of the bed before standing up in the morning"
A nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a PCA pump. Which of the following client statements indicates an understanding of the teaching?
"I should tell the nurse if I can't control my pain with this device"
A nurse is administering an oral medication to an older adult client. The client states "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make?
"I will take your medication order again."
An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a "do not resuscitate" (DNR) case. Which of the following responses should the nurse provide?
"Your provider needs to talk with you concerning your request."
A nurse is teaching a group of older adults about health tests and screenings. Which of the following information should the nurse include?
- "You should have a single dose of the shingles vaccine at age 60." - "You should have the pneumococcal vaccine at age 65 and then every 10." - "You should have visual acuity screening every year."
A visiting nurse is assessing an older adult client. The client lives with their primary caregiver, who is overwhelmed due to working a night shift and caring for children. The nurse should identify which of the following as risks for abuse or neglect in the client?
- The caregiver works night shift and helps with the care of grandchildren -The client requires assistance with bathing and eating
A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take?
-Check on the client hourly -Instruct the client about the use of the call light -Apply an ambulation alarm to the client's leg
A nurse is teaching a class expected changes to the skin in older adults. Which of the following information should the nurse include?
-Increase in skin thinning -Decrease in subcutanous tissue -Decrease in skin hydration
A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan?
-Teach balance and stengthening exercises -Provide information about home safety checks -Lock beds and wheelchairs when not providing care -Place the bedside table within the client's reach
A nurse is collecting data from an older adult client who has chronic obstructive pulmonary disease (COPD), arthritis, cataracts, and a BMI of 18.5. Which of the following findings should the nurse identify as a potential barrier to the client's nutrional goal?
-The client relies on a public transit systtem for transportation -The client potential mobility impairment because of arthritis
A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client?
-Water heater tempt -Throw rugs
A nurse is administering a unit of RBC 350mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr?
117 mL
A nurse is preparing to administer levothyroxine 0.175 mg PO once a day. The amount available is levothyroxine 88 mcg/tablet. How many tablets should the nurse administer per dose?
2 tablets
A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?
300mL
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the client has burned?
54%
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?
A client attempts to climb out of bed and repeatedly states she must get home
A nurse is reviewing the medical records of four older adult clients. The nurse should plan to administer the herpes zoster vaccine to which of the following clients?
A client who takes omeprazole for peptic ulcer disease
A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI?
A client with a weight of 150lb and height of 68 inches.
A nurse is teaching a client who has chronic kidney failure about planning a low-protein diet. The client states, "Why do I have to be concerned about protein?" Which of the following responses should the nurse make?
A low-protein diet reduces the risk for uremia
A nurse is assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestations of which of the following complications?
Acute compartment syndrome
A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications?
Acute compartment syndrome
A nurse is planning care for an older adult client who has herpes zoster. Which of the following interventions should the nurse include in the plain?
Administer analgesics for pain
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan?
Administer furosemide Implement a low-sodium diet Measure the client's abdominal girth
A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?
Buck's extension traction will relieve muscle spasms.
A nurse is teaching an older adult client who has herpes zoster about the order of occurrence of findings associated with this disorder. Identify the order in which the findings typically occur.
B. Paresthesia D. Redness and swelling E. Vesicles F. Weeping blisters A. Crusted lesions C. Postherpetic neuralgia
A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. on the graphic, point and click on the area of the ECG that represents the T-wave.
BOX ON THE FAR RIGHT. This is the T-wave. The ECG waveform of a client who has hyperkalemia will have a tall, peaked T wave. It is usually seen when the potassium level is 6 mEq/L or higher.
A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease. The nurse should expect which of the following findings?
BUN 45 mg/dL and creatinine 8 mg/dL
A nurse is caring for a client who is to have IV urography. Which of the following is a contraindication to this procedure?
Client has an allergy to shellfish.
A nurse is helping an older client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker the nurse should:
Check that the client lifts the walker then places it down in front of her
A nurse is preparing to administer cephalexin oral suspension to an older adult client who has difficulty swallowing pills. Which of the following actions should the nurse take?
Check the client for a penicillin allergy
A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?
Checking capillary refill
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
Cheyne-Strokes respirations
A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? Select all that apply
Color Temperature Sensation
Fracture following a motor-vehicle crash?
Compartment syndrome, loosen the dressing to the splint, asses the client's peripheral pulses, monitor client's neurovascular function and pain level
A nurse is monitoring an older adult immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following?
Confirming the gag reflex
A nurse in a provider's office is assessing an older client whose son reports that the client has been sick with respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?
Confusion
A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect?
Confusion
A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?
Confusion
A nurse is observing the closed chest drainage system of a client who is 25 hr post thoractomy. The nurse notes slow, steady bubbling in the suction chamber. Which of the following actions should the nurse take?
Continue to monitor the client's respiratory status
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?
Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.
A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?
Decrease in kidney function
A nurse is reviewing the medical record of a client who has been on levothyroxine for several months. Which of the following findings indicates a therapeutic response to the medication?
Decrease in level of thyroid stimulating hormone (TSH)
A nurse is teaching a class about physiological changes to hearing in older adult clients. Which of the following should the nurse include?
Decreased ability to hear high-frequency sounds
A nurse is teaching a newly licensed nurse about physiological changes in the digestive system that occur with aging. The nurse should include older adults might experience which of the following physiological changes?
Decreased intestinal peristalsis
A nurse is reviewing the lab findings for a client who developed a fat embolism syndrome following a fracture. Which of the following lab findings should the nurse expect?
Decreased serum calcium level
A nurse is preparing a presentation for a group of community stakeholders who are calling for a plan to decrease violence within the community. Which of the following actions should the nurse include as the first step to the CDC's population-based model for violence prevention?
Define and monitor the problem
A nurse is providing discharge instructions to a client who has asthma and a new prescription for montelukast. The nurse should instruct the client to report which of the following adverse effects to the provider?
Depression
A nurse is providing postmortem care for an adult client. Which of the following actions should the nurse take?
Determine whether the client will have an autopsy Cover the body with a clean sheet and place the arms outside of the sheet Give the client's personal belongings to the family
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?
Difficulty starting the flow of urine
A nurse is teaching a client who has a family history of hemophilia A about manifestations of the disorder. The nurse should include which of the following manifestations in the teaching?
Disabling joint pain
A nurse is teaching a client about the uses of cranberry juice. Which of the following information should the nurse include in the teaching?
Drinking
A nurse is caring for a 24-year old client who reports a recent fall, hitting their head and right shoulder. Complete the following sentence by using the list of options.
Drowsiness Right shoulder pain
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
Dysphagia
A nurse is caring for an older adult client who reports their caregiver has been writing checks in their name without their consent. Which of the following types of abuse is the client experiencing?
Economic
A nurse is developing a plan of care who has cellutitis of the leg. Which of the following interventions should the nurse include in the plan?
Elevate the affected leg on two pillows
A nurse is evaluating the laboratory report for a client who has severe diarrhea and a fever. Which of the following laboratory findings should the nurse identify as an indication that the client has a parasitic infection rather than a bacterial infection?
Elevated eosinophil count
A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan?
Encourage short periods of ambulation
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin Which of the following medications should the nurse administer first?
Epinepherine
A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?
Erythrocyte sedimentation rate (ESR)
A nurse is teaching a client who has fibromyalgia about self-care strategies for managing the disorder. Which of the following information should the nurse include in the teaching?
Establish a regular sleep pattern
A nurse is caring for an older adult client whom the nurse suspects has experienced abuse by a nonpartner. Which of the following principles does the nurse demonstrate by reporting their concern to a supervisor?
Ethical decision-making
A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate?
Evaluate urine for amount and for specific gravity
A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?
Excessive laxative use may cause an electrolye imbalance
A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?
Explain to the client what is about to happen
A nurse is obtaining a medical history from a client who is to tar warfarin therapy and currently uses herbal supplements at home. The nurse should inform the client that which of the following herbal supplements can interact adversely with warfain?
Feverfew
A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as he P wave in the ECG complex?
First one
A nurse is caring for a client who reports having chronic constipation. Which of the following herbal supplements should the nurse recommend?
Flaxseed
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
Flush the NG feeding tube with 30mL of water immediately following medication administration
A nurse is caring for an older adult client in an acute setting. The client is malnourished and has bruising on the upper extremeties. The nurse communicates concerns with the provider and manager. Which of the following actions should the nurse take next?
Follow the facility's process to report suspected abuse
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessmments findings should the nurse expect?
Frothy sputum
A nurse on a medical unit is planning care for an older adult client who takes several medications. Which of the following prescribed medications places the client at risk for orhtostatic hypotension?
Furosemide Telemisartan Duloxetine
A nurse is assisting an older adult client to ambulate who sometimes loses her balance while walking. Which of the following devices should the nurse use in helping the client to ambulate?
Gait belt
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?
Hemolytic
A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?
Hold the cane on the right side to provide support for the weaker leg
A nurse is caring for a client who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated blood pressure. The nurse should suspect which of the following based on the client's manifestations?
Hypervolemia
A nurse is providing teaching to a client who has angina pectoris and a new prescription for nitroglycerin sublingual tablets. Which of the following statements by the client indicates an understanding of the teaching?
I'll dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2 more tablets 5 minutes apart while waiting
A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is scheduled for physical therapy at 0900. Which of the following interventions should the nurse take?
Identify the client's pain level and medicate as needed
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alteration in function should the nurse expect?
Inability to recognize his family members
A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?
Increase dietary intake of raw vegetables
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?
Increased heart rate
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? Select all that apply
Increased heart rate Increased blood pressure Increased respiratory rate
a nurse is assessing an older adult client who is experiencing age-related changes. Which of the following findings should the nurse expect?
Increased joint stiffness
A nurse is planning care for an older adult client. The nurse should plan to monitor the client for which of the following?
Infections of the eye
The nurse is planning an education program on SILDENAFIL to a group of older male clinets. Which of the following information should the nurse include in the education program?
Ingestion of the medication with nitrates causes hypotension
A nurse is planning care for a client who has cystitis. Which of the following interventions should the nurse include in the plan?
Instruct the client to avoid drinking carbonated beverages
A nurse is preparing a client for magnetic resonance imaging (MRI) of the heart and great vessels. Which of the instructions should the nurse include about this test?
It requires removing metal objects like jewelry
A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk?
LDL 172 mg/dL
A nurse is caring for an older adult client who states, " I am afraid that I may fall while walking to the bathroom during the night. " which of the following actions should the nurse take?
Leave a night light on in the clients room.
A nurse is planning care for a client who has an absolute neutrophil count less than 1,000 mm. Which of the following interventions should the nurse include in the plan?
Limit visitors to healthy adults
The nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Maintain an oral airway, apply a cardiac monitor - Thyroid storm - Dysrhythmias, seizures
A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?
Maintain stable blood glucose levels
A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client
Makes up stories when he is unable to remember actual events
A nurse is assessing a client who reports a nevus that has increased in size and an irregularly shaped-lesion that varies in color. These findings are consistent with which of the following medical diagnosis?
Malignant melanoma
A nurse is formulating a teaching plan about herpes zoster for a group of older adults at a community center. The nurse should include which information in the plan?
Many clients experience pain in the affected area for weeks after the lesions have resolved
A nurse is performing a health screening for an older adult client. Which of the following findings should the nurse identify is a health disparity?
Mental health
A client smoking in his bathroom has dropped the discarded cigarette butt into the waste paper basket & it begins to smolder. The nurse recognizes that the priority action would be
Move any client in the immediate vicinity to safety
A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?
Move the client to a room closer to the nurses' station.
A nurse in provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis?
Night sweats, low-grade fever, blood in the sputum
A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?
Pale pink
A nurse is admitting an older client who has diabetic neuropathy with painful, burning feet. Which of the following interventions should the nurse anticipate the health care provider to prescribe?
Place a bed cradle on the client's bed.
A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take?
Place the client on aspiration precautions
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Place the client on his side
A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?
Provide an adaptive feeding device for the client
A nurse is developing a plan of care for a client following a lumbar puncture. Which of the following actions should the nurse include in the plan?
Provide oral fluids, monitor for nausea, check level of consciousness, check sensation in the toes
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
Provide the client with a diet high in protein
A nurse in the emergency department is admitting a client. Each of the following findings in the client's medical record, click to specify if they are consistent with angina or a MI.
Provider consult - Consistent with both MI and Angina Treadmill stress test - angina Results of nutroglycerin therapy - angina Client's initial report of manifestations - consistent with both angina and MI 12 Lead EKG report - consistent with both angina and MI
A nurse is preparing a presentation for a planning board on strategies that would help older adults remain in their homes as they age. Which of the following strategies should the nurse include in the presentation?
Providing assistance with minor home repairs and modifications
A community health nurse is meeting with city leaders to discuss the effectiveness of community-sponsored secondary prevention interventions on the cost of health care for older adults. Which of the following interventions should the nurse suggest?
Providing screening fairs for diabetes and hypertension
A nurse is teaching a client about medications that prevent osteoporosis. The nurse should instruct the client that which of the following medications is prescribe to prevent osteoporosis?
Raloxifene
A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?
Remind the client to look for food on the left side of the tray
A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first?
Report the findings to a supervisor
Nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress
Respiratory Acidosis, Administering IV antibiotics and prescription for bronchodilator, Monitor PaCO2 and papilledema
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PACO of 50 mm Hg?
Respiratory acidosis
A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances?
Respiratory acidosis
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate?
Restrict fluid intake to 1,000 mL per day
A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?
Rigid abdomen
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
Scatter rugs are present in the kitchen
A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognisze as normal sinus rhythm?
The P wave falls before the QRS complex
A nurse is caring for a client who had abdominal surgery 3 days ago.
The client is at risk for developing dehiscene and wound infection
A nurse is caring for an older adult client in an acute setting. The nurse is planning to discharge the client. The nurse should identify which of the following characteristics of the community as risk for neglect or abuse?
The client lives in a neighborhood with many abandoned homes
A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse including in the teaching?
The client shoulder wear dark glasses while outdoors.
A nurse is providing care to an older adult client. Which of the following screening tools should the nurse use to gather data for the client?
The gerontological personality disorder scale
A nurse is caring for a client with a chest tube. Complete the following sentence by using the lists of options.
The nurse should apply a non-occlusive dressing to prevent tension pneumothorax
A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?
The weights rest against the foot of the bed
A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?
This service began with the client's admission to the hospital.
A nurse is reviewing risk factors for osteoporosis with a group of nursing students. The nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis?
Thyroid hormones
A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?
To reduce the risk of stroke in clients who have atrial fibrillation
A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings?
Urine specific gravity 1.002
A nurse arrives for her shift and is preparing to count the controlled substances in the secure cabinet. Which of the following actions should the nurse take?
Verify that the amounts of each medication she counts match the amounts on the inventory record
A nurse is assisting an older adult client who is sedentary plan a new exercise regimen. Which of the following activities should the nurse recommend?
Walking
An occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Which of the following guidelines should the nurse include for emergency care? (Select all that apply.) Wrap the part in dry sterile gauze. Place the severed end of the part into crushed ice. Put the severed part in a dry, waterproof plastic bag. Elevate the extremity. Prevent contact of the severed part with water.
Wrap the part in dry sterile gauze. Put the severed part in a dry, waterproof plastic bag. Elevate the extremity. Prevent contact of the severed part with water.
A nurse is providing teaching to a group of older adults about sources of complete and incomplete protein. Which of the following foods should the nurse include as a complete protein?
Yogurt
A nurse is providing teaching to a client about completing a creatinine clearance test. Which of the following instructions should the nurse include in the teaching?
You will need to avoid rigorous exercise during the test
A nurse is teaching a client who is scheduled for dual-energy x-ray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching?
You will need to remove all jewelry before the test
A nurse is teaching a newly licensed nurse about age-related changes to vision in older adult clients. Which of the following should the nurse include as an example of an expected age-related change?
reduced depth perception
