Health Care of the Older Adult NCLEX
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Question 1 of 5.
Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply.
A. Checking urine for bright blood and a dark smoky color
B. Daily walking as a good exercise
C. Using garlic and ginger, which may decrease bleeding time
D. Performing foot/leg exercises and walking around the airplane cabin on long flights
E. Prevention as the best treatment for DVT
F. Avoiding surface bumps because the skin is prone to injury
Explanation: Rationales: A) Monitoring urine for bleeding is essential on anticoagulants. B) Daily walking promotes circulation, preventing DVT recurrence. D) Foot/leg exercises and movement during flights reduce stasis. F) Avoiding bumps prevents bruising/bleeding due to anticoagulant therapy. C) Garlic and ginger may increase bleeding risk, not decrease it. E) Prevention is vague and not a specific instruction.
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.