Question

A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

Answer 1

Correct Answers:

Decreased sense of balance

Rationale :

🔶 A decreased sense of balance is a common physiologic change associated with aging, due to degeneration of the vestibular system, reduced proprioception, and musculoskeletal changes.

🔶 These changes increase the risk of falls and gait instability in older adults.

🔶 Nurses should assess for postural instability and implement fall precautions when necessary.

🔶 Age-related changes in the inner ear and cerebellum contribute significantly to this finding.

🔶 Preventative measures like home safety education and assistive devices help mitigate injury risk.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Assist the client to select food choices from the menu.

Rationale :

🔶 Selecting food choices is a non-complex task that falls within the scope of assistive personnel (AP) duties.

🔶 It does not require nursing judgment or evaluation, making it suitable for delegation.

🔶 Delegation allows the nurse to focus on more complex tasks such as pain management or teaching.

🔶 APs often assist clients with basic care and comfort needs, which includes dietary preferences.

🔶 The nurse should always ensure the client has no dietary restrictions or allergies before delegation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Peripheral pulses

Rationale :

🔶 When a client has restraints, circulatory compromise is the highest priority, making peripheral pulse assessment the first nursing action.

🔶 Early detection of impaired circulation helps prevent nerve damage, skin breakdown, or even tissue necrosis.

🔶 Restraints can reduce blood flow, especially if not applied correctly or monitored regularly.

🔶 This assessment is part of ensuring safe use of restraints according to patient safety protocols.

🔶 Frequent monitoring ensures adequate perfusion and tissue integrity are maintained.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Explain the need to have another adult drive the client home following surgery.

Rationale :

🔶 Clients undergoing outpatient procedures are commonly given sedation or anesthesia, impairing their ability to drive safely postoperatively.

🔶 Teaching the client to have someone else drive ensures safety and legal compliance.

🔶 Clients may still be drowsy or cognitively impaired following anesthesia, posing a risk to themselves or others if they drive.

🔶 This is a standard preoperative instruction and often a prerequisite for surgical clearance.

🔶 The nurse must ensure the client fully understands and arranges transport prior to discharge.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

This test will provide information about the function of your liver.

Rationale :

🔶 Alanine aminotransferase (ALT) is an enzyme primarily found in the liver, and elevated levels indicate hepatic inflammation or damage.

🔶 It is commonly used to screen for hepatitis, liver toxicity, or liver dysfunction.

🔶 The test is often part of a liver panel, which may also include AST, bilirubin, and ALP.

🔶 It's important for clients taking hepatotoxic drugs or those with risk factors for liver disease.

🔶 Explaining the purpose of the test in simple terms enhances client understanding and cooperation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Arrange for a video conference with an interpreter who speaks the client’s language.

Rationale :

🔶 Using a professional medical interpreter, either in-person or via video, ensures accurate, confidential, and culturally competent communication.

🔶 Family or staff members should not interpret due to risks of inaccurate translation or breach of privacy.

🔶 This approach respects the client’s rights to informed consent and comprehension of discharge or care plans.

🔶 The interpreter helps clarify medical terminology, procedures, and patient questions effectively.

🔶 It’s aligned with evidence-based practices and the Joint Commission’s standards for communication.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Ask a second nurse to record her signature when wasting any unused portion of the controlled substance.

Rationale :

🔶 Controlled substances must be wasted in the presence of a second nurse to prevent drug diversion and ensure accountability.

🔶 The witnessing nurse must document and sign the waste to comply with medication safety regulations.

🔶 This step maintains an accurate record and ensures ethical and legal medication handling.

🔶 It is part of the chain-of-custody process required for all controlled medications.

🔶 Proper disposal and verification reduce the risk of medication errors and legal consequences.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Complete an incident report.

Rationale :

🔶 Anytime a visitor or client is involved in an accident, even without injury, the nurse must complete an incident report for risk management.

🔶 This documentation is used internally to improve safety and does not become part of the medical record.

🔶 It ensures that hospital administration is alerted, and potential hazards are investigated and resolved.

🔶 Early reporting protects both the visitor and facility from future liability or complications.

🔶 The nurse should also monitor the visitor for worsening symptoms while maintaining professionalism.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Crackles in the lungs

Rationale :

🔶 Crackles heard upon auscultation are a sign of fluid accumulation in the lungs, often due to fluid volume excess.

🔶 This can occur when IV fluids are administered too rapidly or in large volumes.

🔶 It is especially dangerous in clients with cardiac or renal compromise, as they may have reduced ability to handle fluid loads.

🔶 Other signs of fluid overload can include edema, dyspnea, and weight gain, but lung crackles are among the earliest and most critical indicators.

🔶 The nurse should notify the provider and anticipate slowing or stopping the infusion.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Prepare the client for a central venous line.

Rationale :

🟨 Parenteral nutrition (PN) with 20% dextrose has a high osmolarity, which requires administration via a central venous access device to avoid phlebitis or vein damage that could occur with peripheral lines.

🟨 Central venous catheters allow for safe infusion of hypertonic solutions, including both high-concentration dextrose and lipid emulsions, into a large central vein.

🟨 Using a central line also enables more consistent blood glucose monitoring, more stable infusions, and reduces the risk of extravasation injuries.

🟨 Administering fat emulsions and dextrose-containing PN can occur simultaneously via a Y-connector, but must be managed via a central line when concentrations exceed 10% dextrose.

🟨 Ensuring central venous access before initiating PN is a standard and essential safety protocol for clients requiring high-caloric intravenous nutrition.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

2 :
A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to assistive personnel?

3 :
A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?

4 :
A nurse is providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching?

5 :
A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

6 :
A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

7 :
A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

8 :
A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?

9 :
A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

10 :
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

QLexNursing

1 : A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

2 : A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to assistive personnel?

3 : A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?

4 : A nurse is providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching?

5 : A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

6 : A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

7 : A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

8 : A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?

9 : A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

10 : A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

1 :
A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

2 :
A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to assistive personnel?

3 :
A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?

4 :
A nurse is providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching?

5 :
A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

6 :
A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

7 :
A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

8 :
A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?

9 :
A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

10 :
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?