Older Adult Exam 4 NCLEX Questions

A client with pneumonia has a temperature of 102.6°F, is diaphoretic, and has a productive cough. The client is able to ambulate. What should the nurse do? A. Change the clients position every four hours B. Use nasal tracheal suctioning to clear secretions C. Change the bedsheets frequently D. Offer the use of a bed pan every two hours

C; frequent changes of the client's bedsheets are appropriate because of the diaphoresis

When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease, the nurse should advise the client to expect for: A. Developed respiratory infections easily B. Maintain current status C. Require less supplemental oxygen D. Slow permanent improvement

A; a client with COPD is at a high risk for development of respiratory infections; Maintaining current status, establishing a goal to reduce oxygen need are unrealistic.

A 79-year-old client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which client information would most likely be a predisposing factor for the diagnosis of pneumonia? A. Age B. Osteoarthritis C. Vegetarian diet D. Daily bathing

A; age is a predisposing factor for development fo bacterial pneumonia.

Which mental status change may occur when a client with pneumonia is experiencing hypoxia? A. Coma B. Apathy C. Irritability D. Depression

C; the initial signs of hypoxia are irritability, restlessness, and confusion

A client with bacterial pneumonia is to be started on IV antibiotics. Which diagnostic test must be completed before antibiotic therapy begins? A. Urinalysis B. Sputum culture C. Chest radiograph D. Red blood cell count

B; a sputum specimen must be collected to determine the causative organism before initiating antibiotic therapy

The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The nurse knows that the client understands the discharge plan when the client: A. Selects a low-cholesterol diet to control coronary artery disease B. States a need for bed rest for 1 week after discharge C. Verbalizes safety precautions needed to prevent pacemaker malfunction D. Explains signs and symptoms of myocardial infarction

C; education is a major component of the discharge plan. The client with a permanent pacemaker must be able to state specific safety requirements of their implanted device.

The nurse is caring for a client with bacterial pneumonia. The effectiveness of the client's oxygen therapy can be best determined by the: A. Absence of cyanosis B. Client's respiratory rate C. Arterial blood gas values D. Client's level of consciousness

C; the client's ABG levels are the most sensitive indicator of the effectiveness of the client's oxygen therapy.

A client with newly diagnosed chronic obstructive disease is to be discharged home with oxygen per nasal problems. Which teaching points should the nurse include in this clients discharge plan? Select all that apply. A. Apply Vaseline or petroleum jelly on lips and nose to prevent dryness and irritation. B. Avoid areas where people are smoking cigarettes or cigars. C. Increase oxygen flow at night during hours of sleep D. Place gauze between the ears and oxygen tubing to prevent skin irritation E. Request a large, pressurized oxygen tank for use during car travel F. Avoid use of a microwave oven when using oxygen

B D; close proximity to smoking, fire, and small electrical appliance can be a fire hazard and should be avoided.

which risk factor would most likely contribute to the development of a hiatal hernia? a. having a sedentary desk job b. being 5 feet, 3 inches tall (160cm) and weighing 190 lbs (86.2kg) c. using laxatives frequently d. being 40 years old

B. any factor that increases intraabdominal pressure can contribute to the development of a hiatal hernia.

which instruction should the nurse include in the teaching plan for a client who is experiencing GERD? a. limit caffeine intake to two cups of coffee per day b. do not lie down for two hours after eating c. follow a low-protein diet d. take medications with milk to limit irritation

B. the nurse should instruct the client to not lie down for about 2 hours after eating to prevent reflux.

During the physical assessment, the nurse should assess the client for signs of atrial fibrillation when palpation of the radial pulse reveals A. Two regular beats followed by one regular beat B. An irregular rhythm with a pulse rate >100 C. Pulse rate below 60 bpm D. A weak, thready pulse

B; characteristics of afib include pulse above 100bpm, totally irregular rhythm, and no definite p waves on the ECG. the nurse is likely to note the irregular rate

The nurse reviews in arterial blood gas Report for a client with chronic obstructive pulmonary disease. The results are as followed pH 7.35, PCO2 62, PO2 70, HCO3 34. The nurse should first: A. Apply 100% non- rebreather mask B. Assessed vital signs C. Reposition the client D. Prepare for intubation

B; clients with COPD have CO2 retention and respiratory drive is stimulated when the PO2 decreases. The vitals should be evaluated to determine if the client is hemodynamically stable.

An older adult is admitted to the telemetry unit for a permanent pacemaker because of sinus bradycardia. What is a priority goal for the client within 24 hours after insertion of a permanent pacemaker? A. Maintain skin integrity B. Maintain cardiac conduction stability C. Decrease cardiac output D. Increase activity level

B; maintaining cardiac condition stability to prevent arrhythmias is a priority immediately after artificial pacemaker implantation.

The nurse administers theophylline (Theo-Dur) to a client. To evaluate the effectiveness of this medication, the nurse should assess for? 1. Suppression of the client's respiratory infection. 2. Decrease in bronchial secretions. 3. less difficulty breathing 4. Thinning of tenacious, purulent sputum.

C. theophylline is a bronchodilator that is administered to relax airways and decrease dyspnea.

a client who has been diagnosed with GERD has heartburn. to decrease the heartburn, the nurse should instruct the client to eliminate which item from the diet? a. lean beef b. air-popped popcorn c. hot chocolate d. raw vegetables

C. with GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus.

A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for: A. A mild but constant aching in the chest B. Severe midsternal pain C. Moderate pain that worsens on inspiration D. Muscle spasm pain that accompanies coughing

C; chest pain with pneumonia is typically caused by friction in the pleural layers

A nurse is assessing a client with chronic emphysema. Which finding requires immediate intervention? A. Using pursed lip breathing and prolonged expiration B. Circumoral cyanosis C. Crackles auscultated posteriorly halfway up the left lung D. Appearance of a barrel chest

C; crackles auscultated in the lung field indicate excessive fluid, a problem that requires immediate intervention.

When caring for the client who is receiving an amino glycoside antibiotic, the nurse should monitor which laboratory value? A. Serum sodium B. Serum potassium C. Serum creatinine D. Serum calcium

C; there is a potential for this type of drug to cause acute tubular necrosis.

the client is scheduled to have an upper gastrointestinal tract series of x-rays. following the x-rays, the nurse should instruct the client to a. take a laxative b. follow a clear liquid diet. c. administer an enema d. take an antiemetic

A. the client should take a laxative after an upper GI series to stimulate a bowel movement. This assessment utilizes barium, which must be promptly removed from the body.

which lifestyle modification should the nurse encourage the client with a hiatal hernia to include in the activities of daily living? a. daily aerobic exercises b. eliminating smoking and alcohol use c. balancing activity and rest d. avoiding high-stress situations

B. smoking and alcohol use both reduce esophageal sphincter tone and can result in reflux.

Which findings are significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply. A. Quality of breath sounds B. Presence of bowel sounds C. Occurrence of chest pain D. Account of peripheral edema E. Color of nail beds

A C E; a respiratory assessment, which includes breath sounds, nail beds, and chest pain is important for clients with pneumonia

When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects: 1. While inhaling through an open mouth. 2. While exhaling through pursed lips. 3. After exhaling but before inhaling. 4. While taking a deep breath and holding it.

B. exhaling requires less energy than inhaling, so lifting while exhaling through pursed lips saves energy.

The client with COPD is taking theophylline. The nurse should instruct the client to report which signs of theophylline toxicity? select all that apply a. nausea b. vomiting c. seizures d. insomnia e. vision changes

a, b, c, d the therapeutic range for serum theophylline is 10-20 mcg/mL. at higher levels the client will experience N/V, seizures, and insomnia.

which dietary measures would be useful in presenting esophageal reflux? a. eating small, frequent meals b. increasing fluid intake c. avoiding air swallowing with meals d. adding bedtime snack to the dietary plan

a. esophageal reflux worsens when the stomach is over distended with food. Therefore, an important measure is to eat small, frequent meals.

The nurse administers to 325 mg aspirin every four hours to a patient with pneumonia. The nurse should evaluate the outcome of administrating the drug by assessing the client for which findings? Select all that apply. A. Decreased pain when breathing B. Prolonged clotting time C. Decreased temperature D. Decreased respiratory rate E. Increased ability to expectorate secretions

A C; aspirin is both an analgesic and an antipyretic

When teaching a patient about self-care following the placement of a new permanent pacemaker to the left upper chest, the nurse should include which information? Select all that apply. A. Take and record daily pulse rate B. Avoid air travel because of airport security alarms C. Immobilize the affected arm for 4-6 weeks D. Avoid using a microwave oven E. Avoid lifting anything heavier than 3 lb

A E; the client should be educated on taking the pulse daily, and avoid lifting heavy objects unless cleared by a HCP.

the nurse is developing a care management plan with a client who has been diagnosed with GERD. what should the nurse instruct the client to do? select all that apply a. avoid a diet high in fatty foods b. avoid beverages that contain caffeine c. eat three meals a day with the largest meal being at dinner in the evening d. avoid all alcoholic beverages e. lie down after consuming each meal for 30 minutes use over the counter anti secretory agents rather than prescriptions

A,B,D. no specific diet is necessary, but foods that cause reflux are avoided, including fatty foods, foods that decrease lower esophageal sphincter pressure, alcohol.

which is a priority goal for the client with COPD? a. maintain functional ability b. minimizing cost pain c. increasing carbon dioxide levels in the blood d. increasing infectious agents

A. A priority goal of COPD is to manage signs and symptoms to maintain functional ability.

A client has been admitted to the coronary care unit. The nurse observes third degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60 mm HG. The nurse should first: A. Prepare for transcutaneous pacing B. Prepare to defibrillate the client at 200 J C. Administer an IV lidocaine infusion D. Schedule the operating room for inception of a permanent pacemaker

A; transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation, and is used temporarily until a trans venous or permanent pacemaker can be inserted.

When instructing clients on how to decrease the risk of chronic obstructive pulmonary disease (COPD), the nurse should emphasize which of the following? 1. Participate regularly in aerobic exercises. 2. Maintain a high-protein diet. 3. Avoid exposure to people with known respiratory infections. 4. Abstain from cigarette smoking.

D. cigarette smoking is the primary cause of COPD and is the priority teaching.

The client with GERD complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions? A. Development of laryngeal cancer B. Irritation of the esophagus C. Esophageal scar tissue formation D. Aspiration of gastric contents

D. clients with GERD can develop pulmonary symptoms such as coughing, wheezing, and dyspnea, that are caused by the aspiration of gastric contents.

the nurse instructs the client on health maintenance activities to help control symptoms from a hiatal hernia. which statement would indicate that the client has understood the instructions? a. "I will avoid lying down after a meal" b. "I can still enjoy my potato chip and cola at bedtime" c. "I wish I did not have to give up my swimming" d. "if I wear a girdle I will have more support for my stomach"

A. a client with a hiatal hernia should avoid the recumbent position immediately after meals to minimize gastric reflux.

the nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. the nurse should ask the client about the presence of which symptoms? a. heartburn b. jaundice c. anorexia d. stomatitis

A. heartburn, the most common symptom of a sliding hiatal hernia, results from reflux of gastric secretions into the esophagus.

A nurse is reviewing the medications used by a client who has chronic bronchitis and a history of high blood pressure and prostate enlargement the nurse should verify that the client understands how do use which medications? Select all that apply. A. Albuterol in ipratropium by metered dose inhaler B. Guaifenesin with dextromethorphan liquid C. Generic pseudoephedrine tablets D. Lisinopril tablets E. Tamulosin

B C; the cough reflex for these clients promotes airway clearance. While the guaifenesin may thin secretions and facilitate expectoration, dextromethorphan suppresses the cough and should not be used with chronic bronchitis

An elderly client admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate? A. Perform circulation checks to bilateral upper extremities each shift B.Attach the ties to the restraints to the bed frame C. Reevaluate the need for restraints and document weekly D. Ensure the restraint prescription has been signed by the healthcare provider (HCP) within 72 hours

B; restraints should be attached to the bed frame, re-evaluation should be performed every 1 to 2 hours, and orders for restraints must be entered by the HCP every 24 hours

Which finding is an expected outcome for an elderly client following treatment for bacterial pneumonia? A. A respiratory rate of 25 to 30 breaths per minute B. The ability to perform activities of daily living without dyspnea C. A maximum loss of 5 to 10 pounds of body weight D. Chest pain that is minimized by splinting the rib cage

B; returning to normal function is the desired outcome.

Which information should the nurse include in a teaching plan for the client newly diagnosed with chronic obstructive pulmonary disease? Select all that apply. A. Pulmonary rehabilitation programs offer very little benefit B. Pneumococcal vaccination is contraindicated for clients with lung disease C. High humidity may increase your work of breathing D. A bronchodilator with metered dose inhaler should be readily available E. Smoking cessation is important to slow her stop disease progression

C D E; carrying a metered dose inhaler can facilitate early intervention if SOB occurs, smoking cessation, vaccination, and pulmonary rehabilitation are all important to pulmonary function.

a client is taking cimetidine to treat a hiatal hernia. the nurse should evaluate the client to determine that the drug has been effective in preventing which health problem? a. esophageal reflux b. dysphagia c. esophagitis d. ulcer formation

C. cimetidine is a histamine receptor antagonist that decreases the quantity of gastric secretions.

which diet would be most appropriate for a client with COPD? a. low fat, low cholesterol diet b. bland, soft diet c. low sodium diet d. high calorie, high protein dietf

D. the client should eat high calorie, high protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing.

A client is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD). The spouse expresses anxiety about what would happen if the device discharges during physical contact. What should the nurse tell the spouse? A. Physical contact should be avoided whenever possible. B. They will not feel the countershock C. The shock will feel like a "tingle", but it will not cause any physical harm D. A warning device sounds before countershock, so there is time to move away

C; there is not a warning device on the ICD, and the spouse is still able to touch the patient. if the ICD were to go off the spouse would feel it, but it would only be a tingle sensation.

the nurse should instruct the client to avoid which drug when taking metoclopramide hydrochloride? a. antacids b. antihypertensives c. anticoagulants d. alcohol

D. Metoclopramide hydrochloride can cause sedation. Alcohol and other central nervous system depressants add to this sedation.

the nurse assesses the respiratory status of a client who is experiencing an exacerbation of COPD secondary to an upper respiratory tract infection. Which findings are expected? a. normal breath sounds b. prolonged inspiration c. normal chest movement d. coarse crackles and bronchi

D. exacerbations of COPD are commonly caused by respiratory infections. Coarse crackles and bronchi would be auscultated as air moves through airways obstructed with secretions.

which statement indicates that the client with COPD, who has been discharged to home, understands the care plan? a. the client will avoid direct contact with family and friends b. the client states actions to reduce pain c. the client will use oxygen via a nasal cannula at 5L/min d. the client agrees to call the healthcare provider if dyspnea on exertion increases

D. increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD and should notify the HCP

Which nursing action would most likely be successful in reducing pleuritic chest pain in the client with pneumonia? A. Encourage the past client to breathe shallowly B. Have a client practiced abdominal breathing C. Offer the client incentive spirometry D. Teach the client to splint the rib cage when coughing

D; the pleuritic pain is triggered by chest movement and is particularly severe during coughing

The nurse is assessing a client with COPD. Which requires immediate intervention? A. Distant heart sounds B. Diminished lung sounds C. Inability to speak D. Pursed lip breathing

C; inability to speak could indicate respiratory distress

In developing a teaching plan for the client with a hiatal hernia, the nurse's assessment of which work-related factors would be most useful? 1. Number and length of breaks. 2. Body mechanics used in lifting. 3. Temperature in the work area. 4. Cleaning solvents used.

B. bending, especially after eating, can cause gasteroesophageal reflux. lifting heavy objects increases intraabdominal pressure.

Bethanechol has been prescribed for a client with GERd. the nurse should assess the client for which adverse effect? a. constipation b. urinary urgency c. hypertension d. dry oral mucosa

B. bethanechol, cholinergic drug, my be used in GERD to increase lower esophageal sphincter pressure and facilitate gastric emptying.

The client with pneumonia develops mild constipation and The nurse administers docusate sodium as prescribed. This drug works by: A. Softening the stool B. Lubricating the stool C. Increasing stool bulk D. Stimulating peristalsis

A; docusate sodium allows fluid and fatty substances to enter the stool, allowing it to pass easier

the nurse is planning to teach a client with COPD how to cough effectively. which instruction should be included? take a deep abdominal breath, bend forward, and cough three or four times on exhalation. b. lie flat on the back, splint the thorax, take two deep breaths, and cough c. take several rapid, shallow breaths, and then cough forcefully d. assume a side lying position, extend the arm over the head, and alternate deep breathing with coughing

A. the goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume sitting position with feet on the floor, bend forward slightly, and exhale using pursed-lip breathing.

Bedrest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bedrest by assessing the client's: A. Decreased cellular demand for oxygen B. Reduced episodes of coughing C. Diminished pain when breathing deeply D. Ability to expectorate secretions more easily

A; exudate in the alveoli interferes with ventilation and the diffusion of gases in lints with pneumonia. It is essential to reduce the body's need for oxygen during the acute phase of the illness

a client with COPD is experiencing dyspnea and has a low PaO2 level. the nurse plans to administer oxygen as prescribed. Which statement is true concerning oxygen administrations to a client with COPD. a. high oxygen concentrations will cause coughing and dyspnea b. high oxygen concentrations may inhibit the hypoxic stimulus to breathe c. increased oxygen will cause the client to become dependent on the oxygen d. administration of oxygen is contraindicated in clients who are using bronchodilators.

B. Clients with COPD may retain CO2. Gradually, the body adjusts to the higher CO2 concentration and the high levels no longer stimulate the respiratory center. The major stimulant then becomes hypoxemia.

the client asks the nurse if surgery is needed to correct a hiatal hernia. which reply by the nurse would be most accurate? a. "surgery is usually required, although medical treatment is attempted firs" b. "Hiatal hernia symptoms can usually be managed with diet modifications, medications, and lifestyle changes." c. "surgery is not performed for this type of hernia" d. "a minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned"

B. most clients can be treated successfully with a combination of diet restrictions, medications, weight control, and lifestyle modifications.

the nurse is teaching a client with chronic obstructive pulmonary disease to assess for signs and symptoms of right sided heart failure. Which signs and symptoms should be included in the teaching plan? a. clubbing of nail beds b. hypertension c. peripheral edema d. increased appetite

C. right sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs/symptoms include peripheral edema, JVD, hepatomegaly, and increased fluid volume.

which nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia? a. introduce the client to other people who are successfully managing their care b. include the client'sdauihter in the teaching so that she can help implement the plan c. ask the client to identify other situations in which the client changed healthcare habits d. provide reassurance that the clients will be able to implement al aspects of the plan successfully

C. self-responsibility is the key to individual health maintenance. Using examples of sutuations in which the client has demonstrated self-responsibility can be reinforcing and supporting.

the client has been taking magnesium hydroxide (milk of mag) to combat hiatal hernia symptoms. the nurse should assess the patient for which condition most commonly associated with the ongoing use of magnesium based antacids? a. anorexia b. weight gain c. diarrhea d. constipation

C. the magnesium salts are related to those in laxatives and may cause diarrhea.

which is an expected outcome of pursed-lip breathing for clients with emphysema? A. to promote oxygen intake b. to strengthen the diaphragm c. to strengthen the intercostal muscles d. to promote carbon dioxide elimination

D. pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting CO2 elimination.

The healthcare 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: A. "Do you have a history of seizures?" B. "Do you have any cardiac history?" C. "Have you had any recent infections?" D. "Have you had a previous allergy to penicillin?"

D; the nurse should determine if the client is allergic to penicillin before administering penicllin

A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in the teaching plan for this client? A. "You will continue to take your medications until the morning of the test" B. "You might be sedated during the procedure and will not remember what happened" C. "This test is a noninvasive method of determining the effectiveness of your medication regimen" D. "During the procedure, the healthcare provider will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms"

D; the purpose of EPS is to study the heart's electrical system. A special wire is introduced into the heart to produce dysrhythmia.