Nur 102 Final Nclex Exam(85 Question

You observe the patient for early signs of hypoxia. You know that the first sign of hypoxia includes:

Increase restlessness or irritability.

Increased respiratory rate.

In providing nursing care for this patient, who is having difficulty breathing, it is important to reduce her anxiety because it:

causes needless fear and worry.

The patient is in pain but doesn't want to take pain medication you know that it is important to keep her comfortable because:

When breathing causes pain, she won't take deep breaths to open alveoli.

There is continuous bubbling in the suction chamber of the disposable water-seal chest drainage unit. With 120 ML of drainage in the last hour. What should you do?

Call the physician

When performing nasophayngeal suctioning. you should:

raise the head of the bed to 30 to 45 degrees.

set suction at 100mm Hg.

Mositen the catheter before attempting suctioning.

When administering oxygen by nasal cannula, it is important to:

Decrease the flow rate, per the physicians order, when oxygen levels are in normal rage.

verify the physicians orders and recognize oxygen as a drug treatment.

educate the patient about the need for oxygen and when to use it.

The most effective way to clear a patients respiratory tract of secretions after a thoractomy and lung resection is to:

Teach her to cough effectively

Older people are more prone to respiratory problems because aging causes which change?

Decreased elasticity of respiratory tissues.

Decrease efficiency of the immune system.

In normal individuals, the drive to breathe and the control of the respiratory rate are dependant on:

The Paco2 level in the blood.

On nursing measure that can prevent respiratory insufficiency is to:

assist the patient to turn, cough, and deep breathe.

Regarding HIV, sexuality, and the older adult:

health care providers are less likely to ask the older patient about their sex practices.

Your neighbor asks your advice on nutrition for her aging parents. You consider your response based on the fact that:

In general, older adults require fewer calories.

One of the most common reasons that elder adults are placed in long-term care facilities is:

incontinence

Which of the following is true regarding sensory deficits in the older adult?

Cleaning excess cerumen can improve hearing.

Dietary recommendations for the elderly include:

between 46 and 56 g/day of protein

The elder with a sensory impairment as a result of the aging process may:

be subjected to safety problems

Measure to try to prevent age-related macular degeneration include :

Sunglasses and a diet of antioxidant foods.

Drug toxicity occurs more easily in the elderly because of:

decrease kidney function.

slower liver metabolism.

Drug use assessment to identify concerns related to polypharmacy should include:

names of the pharmacies used.

The condition most likely to cause a vision loss in the elderly is

Age related macular degeneration

When it comes to learning, the elderly are:

as capable as younger people, but slower to learn.

Confusion is often a reversible condition in patients with

delirium

Measures to keep the cognitively impaired safe in a home environment include:

Placing alarms on the outside doors.

removing knobs from the stove burners and oven at night.

placing an identification bracelet on the person.

Which symptoms is the nurse most likely to observe in a depressed, elderly patient?

Poor memory

Insomnia

Loss of motivation

Medications that work by increasing acetylchorline in the cerebral cortex may produce:

impaired memory, alertness, and social engagement.

You recently admitted a patient with alzhiemers disease to your long term care nursing unit. This patient appears restless and agitated. What should you do first?

Assist the patient in attending his scheduled music group therapy.

When you suspect an elder is considering suicide, the most appropriate intervention is to

ask the patient directly about such plans.

The usual standard for reporting elder abuse is one:

of reasonable belief that abuse has occurred or may occur.

Long-term recovery from alcohol abuse is most likely to occur when:

The patient admits to having a problem

Strategies to help prevent crime include:

Changing door locks after loosing keys.

Using direct deposit for personal funds.

Using an informal buddy system in the neighborhood.

Avoid clicking on an email link from an unexpected or unknown sender.

Your patient, age 72, has COPD and is recovering from a minor motor vehicle accident. He is started on oxygen via nasal cannual. You know that a normal range of oxygen flow for him would be_______.

2-3 L/min

Your patient is breathing shallowly and seems irritable and restless. A nursing action that might help is to have him.

Turn, cough, and deep breathe.

Important actions for the patient undergoing oxygen therapy are to:

safety check electrical equipment.

Cleanse nares frequently.

Check need for humidification.

The physician has ordered nebulizer treatment for your patient. The best time to perform this procedure is

45-60 minutes before meals.

Other nursing actions to assit patients with pneumonia to obtain better oxygenation are to:

Place in semi-fowlers position except when sleeping.

Ambulate them three times per day.

Encourage deep- breathing and coughing.

A factor in keeping the patient's secretions thinned so they can be coughed up-other than using a humidifier-is to:

increase fluid intake

A patient, age 64 has an endotracheal tube in place. She suffered a head injury 6 days ago in a fall and is in comatose. The endotracheal tube should be placed by a tracheostomy tube, if an airway is still needed, after____.

1 week

Francisco pedroza remains comatose and in need of ventilation. A tracheostomy tube is inserted. When suctioning the tracheostomy, you should

use 80-120 mm Hg for suction pressure

For proper technique in suctioning the patients tracheostomy, you would:

rotate the catheter and use suction while pulling the catheter out of the bronchus and trachea.

The patient is receiving positive-pressure ventilation. This means that her cuffed tube must be

inflated for ventilation to be most effective.

Prescribed oxygen flow rates, depending on the patient and the delivery device used, range from _____to____ liters per minute

2 to 12 liters per minute

If suction is being used with a water-seal system, there should be

constant bubbling in the suction chamber

A 69-year old male has fractured his left ankle and sustained a deep abrasion on the lower leg. As his home health nurse, you visit to change the dressing. during the visit, you perform other assessments. As the patient is most immobile because he needs to keep the right leg elevated and because he is taking pain medications, it is especially important to assess his

bowel status

When you asked the patient with a stasis ulcer if she is taking her antibiotics for the infection in her leg, the patient replies, " yes, but I have so many pills, I'm not sure I'm taking them at the right times." What would be a good method to assist her to take her pills during correctly?

Set up a 7-day medication planner for her that you can refill during your nursing visits.

When listing the patient's medications, you find that she has two very similar blood pressure medications prescribed by different doctors. To remedy the problem of polypharmacy, you would recommend that she

obtain all of her prescription medications from one pharmacy.

A patient indicated she is not eating much because it is difficult for her to cook. Nursing interventions that might be appropriate in this care are:

Ask her daughter to bring her several microwave meals.

Suggest using supplements such as ensure to maintain her nutrition.

Ask the social worker to set up a meals on weals service for her.

Your patient has hypertension, asthma, hypothyroidism, and osteoarthritis, which are chronic conditions. As her osteoarthritis worsens, it may affect her_______

mobility

An alert, well-groomed, 82 year old resident of a long term care facility has been experiencing bladder incontinence since she has pneumonia. She seems quiet depressed and you suspect that this development has seriously affected her

self-esteem

The first thing that should be done when beginning a bladder retraining program for a patient is

tracking when incontinence occurs

When considering a teaching session for a patient about the bladder retraining program, you would plan to

eliminate outside noise and distractions.

use printed materials along with explaining the process.

A patient has been having some difficulty with constipation from decreased appetite and anitbiotic therapy. To assist her with this problem you, would encourage her to

increase roughage with fresh fruits and vegetables.

attempt to evacuate the bowels at the same time each day.

A patient has moderate macular degeneration. To decrease the possibility of falls at night, you would

ask her to call for assistance to the bathroom

Your patient has been instructed by her physician to start taking Miacalcin nasal spray. Which statement by the nurse would be most helpful in assisting the patient to understand her new medication

This medication will help to strengthen your bones

A leading cause of hospitalization and placement in long-term care is

hip fracture

Your patient is at risk for falls for a variety of reasons. Which of the following medications would cause you most concern for this patient's fall risk?

Furosemide

Many common physical problems affect older adults. A common physical care problem in older people that has been reported to cost billions of dollars for nursing home care is

Urinary incontinence

Your patient is asking your advise on choosing an activity to promote better balance. Which of the following would be the best answer you could provide to him

Tai Chi

A measure that is usually ordered before removing a fecal impaction is to administer

an oil retention enema

Macular degeneration is a common eye disorder that is characterized by

A gradual loss of central, acute, and color vision

Antioxidants that may help protect against macular degeneration include

Vitamin C and Vitamin E

Presbycusus is characterized by the inability to hear

high-frequency sounds

Strategies to increase compliance in self-medication administration iclude which of the following?

Use of color coded medication bottles,

An alarm clock,

Cueing with daily events

An 85 year old male patient lives with his son. He has come into the clinic for the second time with bruises and abrasions he claims came from a fall. He seems unkempt and says he has difficulty grooming and dressing because of severe arthritis in his hands. He is very this. You know that in order to assess him for elder abuse it is necessary to first

establish a confidential, trusting relationship

The primary goal of psychosocial interventions in a confused and disoriented elder is to

produce a feeling of well-being

If there seems to be a likelyhood of elder abuse involved in a patient's injuries, you know

legally, it must be reported to the authorities

One method of decreasing the possibility of elder abuse is

obtaining help from the caregiver with daily care of the patient

Your neighbor shares with you that two of his older friends have been victims of telemarketing crime lately. He asks for advise on how to avoid this. You tell him

not to order anything over the phone; ask for written information

Your female patient, age 86 is displaying signs of confusion. There are many causes of confusion in older adults, many of which are physiological rather than a problem with the brain. Before assuming that her confusion is related to mental causes, she should be checked for signs of systemic

infection

A patients confusion is worsening. Reality orientation is part of her therapy. Which one of the following would be part of reality orientation?

Displaying memory aids such as a clock and calendar.

The spouse of a recently retired man tells the nurse, " All my husband does is sit around and watch television all day long. He is so irritable and moody. He does not want to talk to me and these days he barely eats anything." Which action should the nurse implement?

Recommend that the client see a healthcare provider.

A patient's confusion becomes worse at about 5:00pm. One intervention that may help decrease her confusion is to

reduce stimulation in the environment

Your male patient, age 80, drinks a lot of alcohol. He is on several medications for his heart disease and hypertension. One danger of alcoholism- in addition to interaction with medication- is

inadequate nutrition

When assessing a patient who may have an alcohol problem, in addition to assessing the drinking pattern, you should look for signs of

underlying depression

strategies to minimize sundowning include

limiting activities and outing to the morning hours

providing soothing music in the late afternoon and evening

Delirium in older adults is often characterized by a(n)

rapid onset

A psychosocial approach for confusion/disorientation that reexamines the past to promote socialization and mental stimulation

reminiscence

Dementia caused by Alzheimer disease is characterized by

memory impairment

suspicion

impaired ability to function in daily life

behavioral symptoms

complaints of vague aches and pains, fatigue, and "just not feeling good" may be indicative of what condition in the elderly?

Depression

The older adult with significant changes in mental functioning should be given a comprehensive mental status examination using a tool such as the ______ or the ____

MMSE(mini mental self exam) or the SPMSQ

Older adults may experience many types of abuse and neglect. Intentionally withholding medication from an older person would be considered

neglect

When counseling older adults on prevention of crime, you would encourage the person

to confirm a service person's ID before allowing him or her entrance to the home

Three conditions that are interrelated and have similar risk factors associated with loss are

alcohol abuse, suicide, and depression

A primary nursing intervention for a depressed patient after he or she has initiated antidepressant therapy is

protection from self-injury

Elder abuse is often related to

caregiver stress and unresolved family conflicts

A type of therapy for a lonely, depressed older adult is often used in long-term care facilities is

PET therapy