NCLEX-RN
Health Care of the Older Adult NCLEX Questions
Extract:
Question 1 of 5
A client with a history of systemic lupus erythematosus was admitted with a severe viral respiratory tract infection and diffuse petechiae. Based on these data, it is most important that the nurse further evaluate the client's recent:
Correct Answer: D
Rationale: Systemic lupus erythematosus (SLE) can cause thrombocytopenia, and diffuse petechiae suggest a low platelet count. Heavy menstrual bleeding is a common manifestation of thrombocytopenia in women and should be evaluated to assess the extent of bleeding and guide treatment. Food, fluid intake, and fatigue are less directly related to the petechiae.
Question 2 of 5
Which assessment is critical for a client receiving thrombolytic therapy?
Correct Answer: B
Rationale: Blood pressure is critical to monitor during thrombolytic therapy to prevent hemorrhagic complications.
Question 3 of 5
A client with a recent amputation reports phantom limb pain. Which intervention should the nurse implement first?
Correct Answer: D
Rationale: Explaining phantom pain validates the client's experience, addressing anxiety before other interventions.
Question 4 of 5
A client arrives from surgery to the postanesthesia care unit. Which of the following respiratory assessments should the nurse complete first?
Correct Answer: A
Rationale: Oxygen saturation is the first respiratory assessment in the PACU, as it quickly indicates oxygenation status and guides further interventions if hypoxia is detected.
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.