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
Give this one a try later!
Coarse and fine crackles
-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.
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
Give this one a try later!
Depression
-A symptom that an older adult is likely to experience with a sudden
change in living accommodations when a loss of personal identity can
crease low self-esteem
An older male client returns to the hospital after discharge 4 days ago for a
transurethral resection of the prostate (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
Give this one a try later!
The tubing that drains the urinary bladder has bright red urine with clots
-The presence of bright red urine with clots in the tubing draining the
bladder is an abnormal finding indicating active bleeding, which should
have resolved after 36 to 72 hours postoperatively and should be reported.
An older male client is admitted for emergency treatment of acute closed-angle
glaucoma. The registered nurse (RN) begins administering the prescribed miotic
medications and glycerin (Glycol) therapy. Which intervention is most important for
the RN to maintain during the client's therapy?
a) Maintain lighting control in the room during therapy
, b) Monitor intake and output q2 hours for 24 hours
c) Place an eye patch over the affected eye during sleep
d) Administer the eye drops at the scheduled intervals
Give this one a try later!
Monitor intake and output q2 hours for 24 hours
-Monitoring intake and output is most important during the administration
of glycerin (Glycol) due to the rapid acting osmotic diuretic effect of
glycerin therapy.
An older client who is unconscious is admitted after experiencing a head injury from a
fall. Glasgow Coma Scale (GCS) is prescribed to evaluate the client. Which focused
assessments should the registered nurse (RN) use to determine the client's GSC
score? (Select all that apply).
a) Verbal response
b) Motor response
c) Eye opening
d) Pupillary reaction
e) Hearing
Give this one a try later!
-Verbal response
-Motor response
-Eye opening
A new resident in an assisted living facility is an older client who is experiencing short-
term memory loss and confusion. Which activity should the registered nurse (RN)
schedule the client to do during the day?
a) Arts and crafts
b) Current events discussion group
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
Give this one a try later!
Coarse and fine crackles
-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.
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
Give this one a try later!
Depression
-A symptom that an older adult is likely to experience with a sudden
change in living accommodations when a loss of personal identity can
crease low self-esteem
An older male client returns to the hospital after discharge 4 days ago for a
transurethral resection of the prostate (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
Give this one a try later!
The tubing that drains the urinary bladder has bright red urine with clots
-The presence of bright red urine with clots in the tubing draining the
bladder is an abnormal finding indicating active bleeding, which should
have resolved after 36 to 72 hours postoperatively and should be reported.
An older male client is admitted for emergency treatment of acute closed-angle
glaucoma. The registered nurse (RN) begins administering the prescribed miotic
medications and glycerin (Glycol) therapy. Which intervention is most important for
the RN to maintain during the client's therapy?
a) Maintain lighting control in the room during therapy
, b) Monitor intake and output q2 hours for 24 hours
c) Place an eye patch over the affected eye during sleep
d) Administer the eye drops at the scheduled intervals
Give this one a try later!
Monitor intake and output q2 hours for 24 hours
-Monitoring intake and output is most important during the administration
of glycerin (Glycol) due to the rapid acting osmotic diuretic effect of
glycerin therapy.
An older client who is unconscious is admitted after experiencing a head injury from a
fall. Glasgow Coma Scale (GCS) is prescribed to evaluate the client. Which focused
assessments should the registered nurse (RN) use to determine the client's GSC
score? (Select all that apply).
a) Verbal response
b) Motor response
c) Eye opening
d) Pupillary reaction
e) Hearing
Give this one a try later!
-Verbal response
-Motor response
-Eye opening
A new resident in an assisted living facility is an older client who is experiencing short-
term memory loss and confusion. Which activity should the registered nurse (RN)
schedule the client to do during the day?
a) Arts and crafts
b) Current events discussion group
