NCLEX-RN
Health Care of the Older Adult NCLEX Questions
Extract:
Question 1 of 5
Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply.
Correct Answer: A,B,D,F
Rationale: Rationales:
A) Monitoring urine for bleeding is essential on anticoagulants.
B) Daily walking promotes circulation, preventing DVT recurrence.
D) Foot/leg exercises and movement during flights reduce stasis. F) Avoiding bumps prevents bruising/bleeding due to anticoagulant therapy.
C) Garlic and ginger may increase bleeding risk, not decrease it. E) Prevention is vague and not a specific instruction.
Question 2 of 5
The client is receiving an I.V. infusion of 5% dextrose in normal saline running at 125 mL/hour. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first:
Correct Answer: A
Rationale: Swelling and hardness indicate infiltration, requiring immediate discontinuation of the infusion to prevent tissue damage.
Question 3 of 5
The nurse is teaching the client about deep-breathing techniques. Which of the following client statements indicates the need for additional education?
Correct Answer: D
Rationale: Taking four deep breaths before coughing is incorrect, as the client should perform deep breaths and cough in a sequence, typically 2-3 breaths followed by a cough, to prevent atelectasis effectively.
Question 4 of 5
The nurse is taking care of a client with Clostridium difficile (C. difficile). The nurse should do which of the following to prevent the spread of infection? Select all that apply.
Correct Answer: D,E
Rationale:
To prevent the spread of C. difficile, washing hands with soap and water (
D) is essential as alcohol-based sanitizers are ineffective against its spores, and wearing a protective gown (E) prevents contamination. A respirator (
A) is unnecessary, sterile gloves (
B) are not required (clean gloves suffice), and alcohol sanitizer (
C) is ineffective. CN: Safety and infection control; CL: Create
Question 5 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.