NCLEX-RN
Health Care of the Older Adult NCLEX Questions
Extract:
Question 1 of 5
A client with a history of hypertension and peripheral vascular disease underwent an aortobifemoral bypass graft. Preoperative medications included pentoxifylline (Trental); metoprolol (Toprol XL); and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are: Temperature 37.2°C; heart rate 132 beats per minute; respiratory rate 20; blood pressure 126/78. Urine output is 50 to 70 mL/hour. The hemoglobin and hematocrit are stable. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider:
Correct Answer: C
Rationale: SBAR: Situation€”postop day 1, heart rate 132 bpm. Background€”aortobifemoral bypass, history of hypertension, on metoprolol preop. Assessment€”tachycardia suggests inadequate beta-blockade, other vitals stable. Recommendation€”restart metoprolol to control heart rate and blood pressure. Pentoxifylline is less urgent, fluids are adequate (urine output normal), and furosemide may cause dehydration.
Question 2 of 5
As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. Which of the following is the most effective nursing intervention to relieve this discomfort?
Correct Answer: A
Rationale: Ambulation stimulates bowel motility, relieving gas pains effectively and safely.
Question 3 of 5
The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown below. Which of the following findings is expected when assessing this client?
Correct Answer: C
Rationale: Incontinence is expected with spinal cord injuries due to disruption of neural control over bowel and bladder.
Question 4 of 5
The nurse is developing a care plan with a client who had a laryngectomy 3 days ago. The nurse should instruct the client to do which of the following to assure adequate nutrition. Select all that apply.
Correct Answer: A,B,C,D
Rationale:
To ensure adequate nutrition post-laryngectomy, the client should monitor weight, sit and lean forward to aid swallowing, check serum albumin for nutritional status, and use enteral feedings as ordered. Manipulating the tube is not recommended to avoid dislodgement.
Question 5 of 5
After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery?
Correct Answer: A,B
Rationale: Peritonitis and thrombophlebitis are significant complications of pelvic surgery like an ileal conduit, due to potential infection or vascular issues. 'Ingestes' appears to be a typo and is not a recognized complication.