NCLEX-RN
Health Care of the Older Adult NCLEX Questions
Extract:
Question 1 of 5
An overweight client taking warfarin (Coumadin) has a nursing diagnosis of ineffective tissue perfusion related to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
Correct Answer: B,C,E
Rationale: Rationales:
B) A reduced-calorie, reduced-fat diet helps manage weight and reduce atherosclerosis progression, improving arterial blood flow.
C) Daily inspection for ulcerations is essential in PVD to detect early skin breakdown due to poor perfusion. E) Using an electric razor minimizes the risk of cuts and bleeding, which is critical for a client on warfarin.
A) Applying lanolin or petroleum jelly is not directly related to improving tissue perfusion.
D) Limiting ADLs is incorrect, as moderate activity promotes circulation unless contraindicated.
Question 2 of 5
The client who does not respond adequately to fluid replacement has an order for an I.V. infusion of dopamine hydrochloride at 5 µg/kg/minute. To determine that the drug is having the desired effect, the nurse should assess the client for:
Correct Answer: B
Rationale: Dopamine at 5 µg/kg/minute primarily increases cardiac output by enhancing myocardial contractility and heart rate, improving perfusion in shock. Renal/mesenteric flow occurs at lower doses, vasoconstriction at higher doses, and preload/afterload reduction is not a primary effect.
Question 3 of 5
Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene?
Correct Answer: A
Rationale: Placing the client on their back increases the risk of aspiration, especially in stroke patients with impaired swallowing. Suction equipment, padded tongue blades, and toothbrushing are appropriate for safe oral hygiene.
Question 4 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 5 of 5
The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which one of the following interventions should the nurse consider?
Correct Answer: C
Rationale: Thickening liquids reduces aspiration risk in Parkinson's patients with dysphagia, as coughing indicates swallowing difficulty. Hyperextending the neck or a clear liquid diet increases aspiration risk, and chin tuck is less universally effective.