A nurse is evaluating an older adult client who expresses concern about the aging process. Which of the following statements made by the client indicates a need for follow-up?

"I do my best to protect my skin from bumps and cuts. It's more fragile now."

"I guess feeling down is just part of aging."

"My hair is thinning. I'm going to go to the wig shop soon."

"I missed my eye appointment, but I rescheduled it."

Answer and Explanation

The Correct Answer is B

Choice A reason: The client's effort to protect their skin due to increased fragility is a normal part of the aging process. As the skin ages, it becomes thinner and less elastic, making it more susceptible to injuries. The client's proactive approach to skin care is appropriate and does not indicate a need for follow-up.

Choice B reason: The statement "I guess feeling down is just part of aging" suggests a possible misconception about mental health and aging. While it's true that older adults may face various challenges that can affect their mood, persistent feelings of sadness or depression are not a normal part of aging and should be addressed. Mental health is as important as physical health, and feeling down can be a sign of depression, which is treatable at any age.

Choice C reason: Concerns about changes in appearance, such as hair thinning, are common as people age. The client's plan to visit a wig shop indicates they are taking steps to manage these changes and maintain their self-esteem. This does not necessarily indicate a need for follow-up unless the hair loss is sudden or accompanied by other symptoms that could suggest an underlying health issue.

Choice D reason: Missing an appointment but taking the initiative to reschedule shows that the client is actively managing their health care. Regular eye exams are important for older adults as they can help detect vision changes and conditions like glaucoma or cataracts early on. This behavior is responsible and does not indicate a need for follow-up.

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Correct Answer is B

Explanation

Choice A reason: Aspirating the catheter to check for a brisk blood return is not typically recommended as a routine action when replacing the dressing of a PICC line used for TPN. This action is performed to verify patency and placement of the catheter, but it is not directly related to the dressing change procedure.

Choice B reason: Using sterile technique for the procedure is essential when replacing the dressing of a PICC line. Maintaining sterility is crucial to prevent infection, as the PICC line provides direct access to the central venous system. The nurse should use sterile gloves and follow aseptic protocols to minimize the risk of introducing pathogens at the catheter insertion site.

Choice C reason: Cleansing the insertion site with hydrogen peroxide is not recommended for PICC line care. Hydrogen peroxide can be damaging to the tissue and may delay healing. Instead, a chlorhexidine-based antiseptic is typically used to clean the skin around the insertion site during dressing changes to reduce microbial flora and prevent infection.

Choice D reason: Flushing the TPN port with 20 mL of 0.9% sodium chloride is a practice used to maintain catheter patency, but it is not part of the dressing change procedure. Flushing is usually done before and after administering medication or nutrition, not specifically during a dressing change.

A. Irrigate the affected eye from the inner corner toward the outer corner. B. Sit the client up with their head turned toward the right side. C. Place a strip of pH paper under the upper lid of the affected eye. D. Irrigate the affected eye using sterile water.

Correct Answer is C

Explanation

Choice A reason: Irrigating the affected eye from the inner corner toward the outer corner is the recommended method for ocular irrigation. This technique helps to flush out the chemical agent without risking further contamination to the other eye or nasal passages.

Choice B reason: Positioning the client sitting up with their head turned toward the right side is appropriate when irrigating the left eye. This position allows gravity to assist in the flow of the irrigation solution away from the unaffected eye, reducing the risk of cross-contamination.

Choice C reason: Placing a strip of pH paper under the upper lid of the affected eye is a critical step in ocular irrigation after a chemical splash. It is used to measure the pH of the ocular surface to ensure that the pH has normalized to a range between 7.0 and 7.2 after irrigation, indicating that the chemical has been adequately flushed out.

Choice D reason: Using sterile water for ocular irrigation is not recommended because it can cause osmotic imbalances and damage to the corneal cells. Instead, normal saline or balanced salt solutions are preferred as they are isotonic and more compatible with the physiological environment of the eye.

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A nurse is evaluating an older adult client who expresses concern about the aging process. Which of the following statements made by the client indicates a need for follow-up?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A nurse is preparing to assist with an ocular irrigation for a client who had a chemical splash to the left eye. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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