Question: An older adult client is admitted to a long-term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?
Answer Options:
A) Absorbent undergarments dry for 6 hours. B) Frequent request for medication to sleep. C) Confusion to time, place, and environment. D) Heel dressing saturated with serous drainage.
Answer: C) Confusion to time, place, and environment.
Question: A client who is terminally ill has an advance directive that stipulates no resuscitative measures are to be taken. The client’s death is imminent, and the family is in the client’s room. The client is currently exhibiting Cheyne-Stokes respirations and has a blood pressure of 60/30 mm Hg. Which is the priority nursing action?
Answer Options:
A) Teach the client’s family how to use an oral suction device to clear the airway. B) Apply an automatic blood pressure cuff and take readings every 15 minutes. C) Elevate the head of the client’s bed and apply oxygen using a face mask. D) Allow privacy for the family and client to express their feelings to one another.
Answer: D) Allow privacy for the family and client to express their feelings to one another.
Question: The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?
Answer Options:
A) Question the client about the frequency of falls in recent months. B) Request to have the client lie as still as possible for the assessment. C) Ask the client how often episodes of sundowning are experienced. D) Assist the client with values clarification about end-of-life care options.
Answer: A) Question the client about the frequency of falls in recent months.
Question: The nurse observes a client demonstrate self-administration of an 80 mL bolus feeding through a gastrostomy tube (GT). The client pours 40 mL of formula into a feeding syringe and allows the solution to flow in by gravity. When the syringe is completely empty, the client adds an additional 40 mL of the formula, followed by 50 mL of water. Which instruction should the nurse provide to the client?
Answer Options:
A) Add the second portion of the feeding before the syringe is completely empty. B) Use 25 mL of water between the two portions of the feeding to flush the GT. C) Raise the syringe barrel higher to increase the flow rate of the bolus feeding. D) Flush the tube with 50 mL of water between the two portions of the feeding.
Answer: A) Add the second portion of the feeding before the syringe is completely empty.
Question: The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?
Answer Options:
A) Remove the coffee from the tray, advising the client that it is not included in the diet. B) Consult with the dietician to learn if the client is allowed to drink coffee. C) Remind the client that no milk or creamer can be added to the coffee. D) Determine which member of the nursing staff brought the cup of coffee to the client.
Answer: C) Remind the client that no milk or creamer can be added to the coffee.
Question: The palliative care nurse is admitting a client who has metastatic bone cancer and is unable to eat or drink without immediate nausea and vomiting. The client is complaining of pain at 9 on a 0 to 10 pain scale, and the vital signs are: heart rate 99 beats/minute, respirations 38 breaths/minute, oxygen saturation 95%, and blood pressure 110/80 mm Hg. Which intervention should the nurse implement?
Answer Options:
A) Medicate with PRN IV narcotic. B) Initiate infusion for an IV fluid bolus. C) Discourage straining on stool. D) Administer an IV antiemetic.
Answer: A) Medicate with PRN IV narcotic.
Question: An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client’s teaching plan?
Answer Options:
A) Intercourse positions that can help prevent tears. B) The importance of using vaginal lubricants. C) Voiding after intercourse to reduce infection. D) Need for scheduling annual well-woman exams.
Answer: B) The importance of using vaginal lubricants.
Question: A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?
Answer Options:
A) Decrease the rate of the feeding by half. B) Observe for an allergic reaction to the formula. C) Stop the tube feeding and assess the client. D) Hang a new bag of the enteral formula.
Answer: C) Stop the tube feeding and assess the client.
Question: A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?
Answer Options:
A) Notify the healthcare provider of the situation. B) Add another hour to the urine collection period. C) Notify the charge nurse of the problem. D) Discard the urine and start another 24-hour period.
Answer: D) Discard the urine and start another 24-hour period.
Question: Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?
Answer Options:
A) Notify the healthcare provider of the client’s concerns. B) Obtain a bedside commode for the client to use. C) Place the bedpan within the reach of the client. D) Ask an unlicensed assistive personnel to stay with the client.
Answer: B) Obtain a bedside commode for the client to use.
Question: The nurse is demonstrating three-point gait crutch walking to an older adult man who broke his foot while playing soccer with his grandchildren. Which behavior indicates that the client understands proper crutch walking?
Answer Options:
A) Practices bicep and triceps isometric exercises. B) Inspects crutches to ensure rubber tips are intact. C) Bears body weight on the palms of hands during the crutch gait. D) Progresses to foot touchdown and weight-bearing of the affected leg.
Answer: C) Bears body weight on the palms of hands during the crutch gait.
Question: Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis?
Answer Options:
A) Bran muffin, mixed fruit, and orange juice. B) Bagel with jelly and skim milk. C) Granola bar and grapefruit juice. D) Egg whites, toast, and coffee.
Answer: B) Bagel with jelly and skim milk.
Question: In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?
Answer Options:
A) Functional capacity. B) Developmental stage. C) Medical diagnoses. D) Age and gender.
Answer: A) Functional capacity.