Health Care of the Older Adult NCLEX
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Question 1 of 5.
The client with a cataract tells the nurse that she is afraid of being awake during eye surgery. Which of the following responses by the nurse would be the most appropriate?
A. Have you ever had any reactions to local anesthetics in the past?
B. What is it that disturbs you about the idea of being awake?
C. With a local anesthetic, you won't have nausea and vomiting after the surgery.
D. There's really nothing to fear about being awake. You'll be given a medication that will help you relax.
Explanation: The nurse should give a client who seems fearful of surgery an opportunity to express her feelings. Only after identifying the client's concerns can the nurse address them appropriately. Asking about previous reactions to anesthetics or discussing nausea does not address the client's fear. Minimizing the client's feelings by saying there is nothing to fear ignores her concerns.
Question 2 of 5.
The physician orders continuous I.V. nitroglycerin infusion for the client with myocardial infarction. Essential nursing actions include which of the following?
A. Obtaining an infusion pump for the medication.
B. Monitoring blood pressure every 4 hours.
C. Monitoring urine output hourly.
D. Obtaining serum potassium levels daily.
Explanation: An infusion pump ensures accurate delivery of nitroglycerin, which requires precise titration. BP monitoring should be more frequent (e.g., every 15-30 minutes), and urine output and potassium levels are not primary concerns.
Question 3 of 5.
A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to:
A. Call for the physician.
B. Start an I.V. line.
C. Obtain a portable chest radiograph.
D. Draw blood for laboratory studies.
Explanation: Indigestion in a client with cardiac risk factors may indicate an MI. Calling the physician promptly ensures rapid evaluation and intervention, such as ECG or medications.
Question 4 of 5.
Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 a.m., the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first?
A. Administer the medications.
B. Call the physician.
C. Withhold the captopril.
D. Question the metoprolol dose.
Explanation: The potassium level of 6.8 mEq/L indicates hyperkalemia, a risk with captopril (an ACE inhibitor). Calling the physician is the priority to address this critical lab value.
Question 5 of 5.
A client has returned to the medical-surgical unit after a cardiac catheterization. Which is the most important initial postprocedure nursing assessment for this client?
A. Monitor the laboratory values.
B. Observe neurologic function every 15 minutes.
C. Observe the puncture site for swelling and bleeding.
D. Monitor skin warmth and turgor.
Explanation: Observing the puncture site for swelling and bleeding is critical post-catheterization to detect complications like hematoma or hemorrhage.