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Health Care of the Older Adult NCLEX Questions

Extract:

The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 4 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.


Question 1 of 5

For each possible intervention, click to specify if the intervention is essential or contraindicated.

Intervention Indicated Not Indicated
Seizure precautions
Request a prescription for dextrose 5% in water (D5W)
Measure axillary temperature frequently
Apply a cooling blanket
Encourage the client to consume cool liquids
Establish continuous cardiac monitoring
Insert an indwelling urinary drainage catheter

Correct Answer: A,B,C,D,E,F,G

Rationale: A (Essential), B (Contraindicated), C (Contraindicated), D (Essential), E (Contraindicated), F (Essential), G (Essential). Seizure precautions, cooling blanket, cardiac monitoring, antipyretics, catheter, and clothing removal are essential for heat stroke management. D5W risks fluid overload, axillary temperature is unreliable, and oral fluids are unsafe due to altered mental status.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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