NCLEX-RN
Health Care of the Older Adult NCLEX Questions
Extract:
Question 1 of 5
The nurse is reading the results of a tuberculin skin test (see fi gure). The nurse should interpret the results as:
Correct Answer: C
Rationale: The tuberculin test is positive. The test should be interpreted 2 to 3 days after administering the purifi ed protein derivative (PP
D) by measuring the size of the fi rm, raised area (induration). Positive responses indicate that the client may have been exposed to the tuberculosis bacteria. A negative response is indicated by the absence of a fi rm, raised area, or an area that is less than 5 mm in diameter. Since the test is positive, it is not necessary to redo the test. The test is positive, not false.
Question 2 of 5
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.
Question 3 of 5
Which of the following represents the most appropriate nursing intervention for a client with pruritus caused by cancer or the treatment?
Correct Answer: D
Rationale: Medicated cool baths soothe the skin and reduce pruritus, a common symptom in cancer patients, without the systemic effects of antihistamines or steroids.
Question 4 of 5
Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation?
Correct Answer: C
Rationale: Internal bleeding in DIC can cause blood accumulation in the abdominal cavity, leading to increasing abdominal girth. Bradycardia and hypertension are not typical, and petechiae are associated with cutaneous bleeding.
Question 5 of 5
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the I.V. line. Which nursing intervention protects the client without increasing her increased intracranial pressure (ICP)?
Correct Answer: B
Rationale: Soft mitten restraints prevent the client from pulling out the I.V. without restricting circulation or increasing ICP, unlike jacket or wrist restraints, which can cause agitation or pressure. Tucking arms under a drawsheet is unsafe and ineffective.