NCLEX-RN
Health Care of the Older Adult NCLEX Questions
Extract:
Question 1 of 5
The physician orders continuous I.V. nitroglycerin infusion for the client with myocardial infarction. Essential nursing actions include which of the following?
Correct Answer: A
Rationale: An infusion pump ensures accurate delivery of nitroglycerin, which requires precise titration. BP monitoring should be more frequent (e.g., every 15-30 minutes), and urine output and potassium levels are not primary concerns.
Question 2 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 3 of 5
The nurse teaches the client how to instill nose drops. Which of the following techniques is correct?
Correct Answer: B
Rationale: Blowing the nose gently before instilling nose drops clears the nasal passages, allowing better medication absorption. Sterile technique is not typically required for home use. Using a new dropper each time is impractical. The head should be tilted back, not forward, after administration to allow the drops to spread.
Question 4 of 5
The client asks the nurse whether he will need surgery to correct his hiatal hernia. Which reply by the nurse would be most accurate?
Correct Answer: B
Rationale: Most hiatal hernias are managed effectively with diet, medications, and lifestyle changes, making this the most accurate response.
Question 5 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.