• NURS 5461 Exam 09/11/2026
NURS 5461 / NURS5461 (Latest Update 2026 /
2027) Adult Gerontology 1 Management Across
the Continuum of Care | Questions & Answers |
Grade A | 100% Correct - UTA
The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action
should the nurse take first?
A.
Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
B.
Sit quietly in the client's room until the client leaves the bathroom.
C.
Allow the client to cry alone and leave the client in the bathroom.
D.
Talk to the client and attempt to find out why the client is crying. - Correct Answer :D
P 1
, • NURS 5461 Exam 09/11/2026
Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's
situation is needed. Option A is incorrect; the nurse should implement the intervention. The nurse may offer to
stay nearby after first assessing the situation more fully. Although option C may be correct, the nurse should
determine if the client's safety is compromised and offer assistance, even if it is refused.
One week after being told that she has terminal cancer with a life expectancy of 3 weeks, the client tells the
nurse, "I think I will plan a big party for all my friends." How should the nurse respond?
A.
"You may not have enough energy before long to hold a big party."
B.
"Do you mean to say that you want to plan your funeral and wake?"
C.
"Planning a party and thinking about all your friends sounds like fun."
D.
"You should be thinking about spending your last days with your family." - Correct Answer :C
Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the
nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not
plan a party. Option B puts words in the client's mouth that may not be accurate. The nurse should support the
client's goals rather than telling the client how to spend her time.
An older male client returns to the hospital after discharge 4 days ago for a TURP. The registered nurse (RN)
evaluates the function of the 3-way indwelling urinary catheter and the continuous bladder irrigation system.
Which finding should the RN report to the healthcare provider?
A. Irrigation bag of normal saline is hanging at the level of the client's head
B. The urinary output is greater than the amount of irrigation fluid instilled
C. The irrigation tubing is attached to the irrigation port on the 3-way catheter
D. The tubing that drains the urinary bladder has bright red urine with clots. - Correct Answer :(D) The tubing
that drains the urinary bladder has bright red urine with clots.
Rationale: The presence of bright red urine with clots in the tubing draining the bladder (D) is an abnormal
finding indicating active bleeding, which should have resolved 36-72 hours postoperatively and should be
reported. (A, B and C) indicate that the system is functioning properly.
P 2
, • NURS 5461 Exam 09/11/2026
An older client who recently moved into an assisted living community refuses to eat or join any activities. When
evaluating the client further, what should the registered nurse (RN) focus on during the next examination?
A. Anxiety
B. Depression
C. Exhaustion
D. Confusion - Correct Answer :(B) Depression
Rationale: Depression is a symptom that an older client is likely to experience with a sudden change in living
accommodations when a loss of personal identity can create low self-esteem. (A, C and D) are other symptoms
that the client can exhibit, but with the sudden change in lifestyle, (B) is most likely and most important for the
RN to focus on.
An older client who is a resident in a long-term care facility is receiving medications through a gastric tube (GT).
After interrupting the continuous GT feeding in which sequence should the nurse implement these actions for
administration of crushed medications? (Arrange in order from first to last step.)
A. Flush the feeding tube of feeding solution
B. Crush the medication into a powder or fine granules
C. Administer each medication separately
D. Dissolve each crushed medication in a medicine cup
E. Flush GT to clear the medication from the tubing
F. Reconnect the gastric feeding tube - Correct Answer :B - D - A - C - E - F
Rationale: The sequence begins with crushing and dissolving the medications. Then flushing the GT of feeding
formula and giving each medication separately. When all medications have been given, the feeding tubing
should be flushed to clear the medication, and the GT should be reconnected. If the medications are compatible
with food, the continuous GT formula can be restarted.
The registered nurse (RN) is caring for an elderly client with functional incontinence who lives in an assisted living
community. The client is alert and mildly confused and can self-ambulate. Which nursing intervention should the
RN implement?
A. Offer assistance with toileting q2 hours
B. Use protective disposal undergarment instead of underwear
P 3
, • NURS 5461 Exam 09/11/2026
C. Ask if the client has attempted to void q2 hours
D. Obtain a prescription for intermittent catheterization - Correct Answer :(A) Offer assistance with toileting q2
hours
Rationale: Maintaining independence and self-esteem is important for an older client with incontinence. (A)
decreases the client's chances of accidents and embarrassment by introducing a toilet training program. (B) is
not implemented unless toileting program is unsuccessful and the client's mental status declines. A confused
client will not remember how many times he or she frequented the toilet, so (C) is not helpful for the client. (D) is
not indicated for clients with functional intolerance and who can ambulate.
The home health registered nurse (RN) is reinforcing instructions to the family about how to prevent pressure
ulcers for their older family member who is bedridden. Which measure should the RN discuss?
A. Lift the client when turning instead of sliding
B. Massage directly over reddened sites
C. Change client's position every 4 hours
D. Place pillows under both the knees - Correct Answer :(A) Lift the client when turning instead of sliding
Rationale: Lifting instead of sliding (A) decreases chances of friction and shearing while moving the client. (B) is
not recommended for tissue that show signs of early pressure, such as a stage 1 site. (D) does not reduce risk for
pressure ulcers. Reposition q2 hours, not q4 hours (C), provides the most benefit in reducing pressure ulcer
formation.
An older male client is admitted to the hospital with left-sided heart failure (HF). Which finding should the
registered nurse (RN) document that is consistent with HF?
A. Ascites
B. Pitting edema
C. Jugular distention
D. Coarse and fine crackles - Correct Answer :(D) Coarse and fine crackles
Rationale: In left-sided heart failure, the inadequacy of pumping blood into the aorta causes blood to back up
into the pulmonary capillaries; this pushes intravascular fluid into the alveoli, which is manifested as crackles or
rales. (A, B and C) are manifested in right-sided heart failure.
P 4
NURS 5461 / NURS5461 (Latest Update 2026 /
2027) Adult Gerontology 1 Management Across
the Continuum of Care | Questions & Answers |
Grade A | 100% Correct - UTA
The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action
should the nurse take first?
A.
Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
B.
Sit quietly in the client's room until the client leaves the bathroom.
C.
Allow the client to cry alone and leave the client in the bathroom.
D.
Talk to the client and attempt to find out why the client is crying. - Correct Answer :D
P 1
, • NURS 5461 Exam 09/11/2026
Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's
situation is needed. Option A is incorrect; the nurse should implement the intervention. The nurse may offer to
stay nearby after first assessing the situation more fully. Although option C may be correct, the nurse should
determine if the client's safety is compromised and offer assistance, even if it is refused.
One week after being told that she has terminal cancer with a life expectancy of 3 weeks, the client tells the
nurse, "I think I will plan a big party for all my friends." How should the nurse respond?
A.
"You may not have enough energy before long to hold a big party."
B.
"Do you mean to say that you want to plan your funeral and wake?"
C.
"Planning a party and thinking about all your friends sounds like fun."
D.
"You should be thinking about spending your last days with your family." - Correct Answer :C
Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the
nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not
plan a party. Option B puts words in the client's mouth that may not be accurate. The nurse should support the
client's goals rather than telling the client how to spend her time.
An older male client returns to the hospital after discharge 4 days ago for a TURP. The registered nurse (RN)
evaluates the function of the 3-way indwelling urinary catheter and the continuous bladder irrigation system.
Which finding should the RN report to the healthcare provider?
A. Irrigation bag of normal saline is hanging at the level of the client's head
B. The urinary output is greater than the amount of irrigation fluid instilled
C. The irrigation tubing is attached to the irrigation port on the 3-way catheter
D. The tubing that drains the urinary bladder has bright red urine with clots. - Correct Answer :(D) The tubing
that drains the urinary bladder has bright red urine with clots.
Rationale: The presence of bright red urine with clots in the tubing draining the bladder (D) is an abnormal
finding indicating active bleeding, which should have resolved 36-72 hours postoperatively and should be
reported. (A, B and C) indicate that the system is functioning properly.
P 2
, • NURS 5461 Exam 09/11/2026
An older client who recently moved into an assisted living community refuses to eat or join any activities. When
evaluating the client further, what should the registered nurse (RN) focus on during the next examination?
A. Anxiety
B. Depression
C. Exhaustion
D. Confusion - Correct Answer :(B) Depression
Rationale: Depression is a symptom that an older client is likely to experience with a sudden change in living
accommodations when a loss of personal identity can create low self-esteem. (A, C and D) are other symptoms
that the client can exhibit, but with the sudden change in lifestyle, (B) is most likely and most important for the
RN to focus on.
An older client who is a resident in a long-term care facility is receiving medications through a gastric tube (GT).
After interrupting the continuous GT feeding in which sequence should the nurse implement these actions for
administration of crushed medications? (Arrange in order from first to last step.)
A. Flush the feeding tube of feeding solution
B. Crush the medication into a powder or fine granules
C. Administer each medication separately
D. Dissolve each crushed medication in a medicine cup
E. Flush GT to clear the medication from the tubing
F. Reconnect the gastric feeding tube - Correct Answer :B - D - A - C - E - F
Rationale: The sequence begins with crushing and dissolving the medications. Then flushing the GT of feeding
formula and giving each medication separately. When all medications have been given, the feeding tubing
should be flushed to clear the medication, and the GT should be reconnected. If the medications are compatible
with food, the continuous GT formula can be restarted.
The registered nurse (RN) is caring for an elderly client with functional incontinence who lives in an assisted living
community. The client is alert and mildly confused and can self-ambulate. Which nursing intervention should the
RN implement?
A. Offer assistance with toileting q2 hours
B. Use protective disposal undergarment instead of underwear
P 3
, • NURS 5461 Exam 09/11/2026
C. Ask if the client has attempted to void q2 hours
D. Obtain a prescription for intermittent catheterization - Correct Answer :(A) Offer assistance with toileting q2
hours
Rationale: Maintaining independence and self-esteem is important for an older client with incontinence. (A)
decreases the client's chances of accidents and embarrassment by introducing a toilet training program. (B) is
not implemented unless toileting program is unsuccessful and the client's mental status declines. A confused
client will not remember how many times he or she frequented the toilet, so (C) is not helpful for the client. (D) is
not indicated for clients with functional intolerance and who can ambulate.
The home health registered nurse (RN) is reinforcing instructions to the family about how to prevent pressure
ulcers for their older family member who is bedridden. Which measure should the RN discuss?
A. Lift the client when turning instead of sliding
B. Massage directly over reddened sites
C. Change client's position every 4 hours
D. Place pillows under both the knees - Correct Answer :(A) Lift the client when turning instead of sliding
Rationale: Lifting instead of sliding (A) decreases chances of friction and shearing while moving the client. (B) is
not recommended for tissue that show signs of early pressure, such as a stage 1 site. (D) does not reduce risk for
pressure ulcers. Reposition q2 hours, not q4 hours (C), provides the most benefit in reducing pressure ulcer
formation.
An older male client is admitted to the hospital with left-sided heart failure (HF). Which finding should the
registered nurse (RN) document that is consistent with HF?
A. Ascites
B. Pitting edema
C. Jugular distention
D. Coarse and fine crackles - Correct Answer :(D) Coarse and fine crackles
Rationale: In left-sided heart failure, the inadequacy of pumping blood into the aorta causes blood to back up
into the pulmonary capillaries; this pushes intravascular fluid into the alveoli, which is manifested as crackles or
rales. (A, B and C) are manifested in right-sided heart failure.
P 4
