NCLEX-RN
Health Care of the Older Adult NCLEX Questions
Extract:
Question 1 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 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
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 4 of 5
Prior to being transported to the surgery suite, the nurse asks the client whether he has any allergies. The client responds, 'Doesn't anyone communicate with anyone? I have been asked that question over and over!' What is the nurse's best response?
Correct Answer: D
Rationale: Explaining that repeated allergy checks are for safety and verification reassures the client while clarifying the purpose of the question. This response addresses the client's frustration and emphasizes the importance of the process.
Question 5 of 5
A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing information about the surgical procedure. Which of the following explanations is most accurate?
Correct Answer: B
Rationale: The Billroth II procedure involves anastomosis of the gastric stump to the jejunum, bypassing the duodenum. The other options are incorrect descriptions of the procedure.