NCLEX-RN
Health Care of the Older Adult NCLEX Questions
Extract:
Question 1 of 5
Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube?
Correct Answer: B
Rationale: Thermal burns to the head, face, and airway can cause swelling and obstruction, leading to hypoxia and requiring airway management like endotracheal intubation or tracheostomy.
Question 2 of 5
A client arrives from surgery to the postanesthesia care unit. Which of the following respiratory assessments should the nurse complete first?
Correct Answer: A
Rationale: Oxygen saturation is the first respiratory assessment in the PACU, as it quickly indicates oxygenation status and guides further interventions if hypoxia is detected.
Question 3 of 5
The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube:
Correct Answer: D
Rationale: A chest tube in pneumothorax removes air and fluid from the pleural space, restoring lung expansion. It is not used for oxygen, scar tissue, or antibiotics.
Question 4 of 5
The nurse is developing a care plan with a client who had a laryngectomy 3 days ago. The nurse should instruct the client to do which of the following to assure adequate nutrition. Select all that apply.
Correct Answer: A,B,C,D
Rationale:
To ensure adequate nutrition post-laryngectomy, the client should monitor weight, sit and lean forward to aid swallowing, check serum albumin for nutritional status, and use enteral feedings as ordered. Manipulating the tube is not recommended to avoid dislodgement.
Question 5 of 5
A nurse is caring for a client with lung cancer who develops syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory finding should the nurse expect?
Correct Answer: A
Rationale: SIADH causes water retention, diluting serum sodium, so a low sodium level (128 mEq/L) is expected due to the inappropriate secretion of antidiuretic hormone.