Question: When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?
Answer Options:
A) Provide frequent rest periods for the client. B) Speak slowly and distinctly to the client. C) Allow additional time to complete tasks. D) Place assistive devices within reach.
Answer: D) Place assistive devices within reach.
Question: A male client tells the nurse that he is taking large doses of a fish oil supplement to lower his triglyceride level. Which action should the nurse take?
Answer Options:
A) Teach the client that all types of oils increase cholesterol and triglycerides. B) Reassure the client that eating large amounts of fish products is heart-healthy. C) Advise the client that high doses of fish oils can increase the risk for bleeding. D) Encourage the client to increase the dose unless GI symptoms develop.
Answer: C) Advise the client that high doses of fish oils can increase the risk for bleeding.
Question: During transfer to the medical unit, a client who experienced an acute change in the level of consciousness became increasingly confused and combative, justifying soft wrist restraints for the client’s upper and lower extremities. Which intervention is most important for the nurse to implement on admission?
Answer Options:
A) Schedule a sitter around the clock. B) Determine baseline neurologic status. C) Administer an IV anxiolytic medication. D) Assess peripheral oxygen saturation.
Answer: D) Assess peripheral oxygen saturation.
Question: An older female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client?
Answer Options:
A) Offer emotional support and explain that urinary incontinence is a common occurrence among older women. B) Apply disposable undergarments and change frequently to prevent skin breakdown. C) Limit fluid intake during the evening meal and throughout the evening hours until bedtime. D) Decrease time intervals between toileting assistance and encourage Kegel exercises.
Answer: D) Decrease time intervals between toileting assistance and encourage Kegel exercises.
Question: An adolescent client who recently lost most sight in both eyes has been admitted for evaluation. The nurse observes an unlicensed assistive personnel (UAP) who is assisting the client to walk in the hallway for the first time since admission. Which action should the nurse take?
Answer Options:
A) Encourage the UAP to continue to assist the client down the hallway. B) Instruct the UAP to guide the client back to his room right away. C) Demonstrate to the UAP how to assist the client with ambulation more safely. D) Advise the UAP to stay nearby but allow the client to ambulate independently.
Answer: C) Demonstrate to the UAP how to assist the client with ambulation more safely.
Question: A client is ambulating with a two-wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client’s elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?
Answer Options:
A) Offer to adjust the height of the walker. B) Explain the need to remove the wheels from the walker. C) Demonstrate more coordinated movement of the legs and walker. D) Encourage the client to continue using the walker as observed.
Answer: D) Encourage the client to continue using the walker as observed.
Question: An older adult client is preparing to ambulate for the first time since experiencing a myocardial infarction three days ago. Which intervention is most important for the nurse to include in the plan of care?
Answer Options:
A) Obtain client’s vital signs every 4 hours when awake. B) Provide client with dietary teaching regarding a cardiac diet. C) Obtain a blood pressure reading before the client gets out of bed. D) Measure and record the client’s urinary output every day.
Answer: C) Obtain a blood pressure reading before the client gets out of bed.
Question: An older adult client grimaces and demonstrates guarding behavior but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?
Answer Options:
A) Document that the client denies pain in the nurse’s notes. B) Administer a PRN dose of a prescribed analgesic. C) Ask the client to describe how they are feeling. D) Confront the client about inconsistent behavior and response.
Answer: C) Ask the client to describe how they are feeling.
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.