A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?

Urinary hesitancy

Dysphagia

Swollen gums

Pruritus

Answer and Explanation

The Correct Answer is B

Choice A Reason: This choice is incorrect because urinary hesitancy is not the priority finding for the nurse to address.

Urinary hesitancy is a difficulty or delay in starting or maintaining a urine stream. It may be caused by various factors such as prostate enlargement, urinary tract infection, medication side eﬀects, or psychological issues. It may cause discomfort, pain, or urinary retention, but it does not pose an immediate threat to the client's life.

Choice B Reason: This choice is correct because dysphagia is the priority finding for the nurse to address. Dysphagia is a difficulty or inability to swallow food or liquids. It may be caused by various factors such as stroke, Parkinson's disease, dementia, esophageal cancer, or oral infections. It may cause malnutrition, dehydration, aspiration, or choking, which can lead to serious complications such as pneumonia, sepsis, or death. Therefore, the nurse should assess the client's swallowing function and provide appropriate interventions such as modifying the diet texture, using thickening agents, or teaching swallowing techniques.

Choice C Reason: This choice is incorrect because swollen gums are not the priority finding for the nurse to address. Swollen gums are an inﬂammation or enlargement of the gingival tissue that surrounds the teeth. They may be caused by various factors such as poor oral hygiene, gum disease, vitamin deficiency, medication side eﬀects, or hormonal changes. They may cause bleeding, pain, or infection, but they do not pose an immediate threat to the client's life.

Choice D Reason: This choice is incorrect because pruritus is not the priority finding for the nurse to address. Pruritus is a sensation of itching that aﬀects the skin. It may be caused by various factors such as dry skin, allergies, eczema, psoriasis, liver disease, or kidney disease. It may cause discomfort, scratching, or skin damage, but it does not pose an immediate threat to the client's life.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because preparing for mechanical ventilation is not the priority nursing intervention, as it is an invasive and potentially harmful procedure that should be reserved for clients who have severe respiratory failure and cannot maintain adequate oxygenation with noninvasive methods.

Choice B Reason: This is correct because administering oxygen via face mask is the priority nursing intervention, as it is a noninvasive and eﬀective way to improve oxygenation and reduce hypoxemia in a client who has low PaO2 and SaO2. Oxygen therapy can also decrease the workload of the heart and lungs and prevent further complications.

Choice C Reason: This is incorrect because preparing to administer a sedative is not the priority nursing intervention, as it may worsen the client's respiratory status and mask the signs and symptoms of hypoxemia. Sedatives should be used with caution and only after oxygenation has been optimized.

Choice D Reason: This is incorrect because assessing for indications of pulmonary embolism is not the priority nursing intervention, as it is a diagnostic rather than a therapeutic action. Pulmonary embolism is a possible cause of the client's condition, but it does not address the immediate problem of hypoxemia.

A. Reduce edema of the brain. B. Increase cell size in the brain. C. Expand extracellular ﬂuid volume. D. Provide ﬂuid hydration.

Correct Answer is A

Explanation

Choice A Reason: This is correct because an osmotic diuretic, such as mannitol, works by creating an osmotic gradient that draws ﬂuid from the brain tissue into the blood vessels, thereby reducing cerebral edema and intracranial pressure.

Choice B Reason: This is incorrect because an osmotic diuretic would decrease, not increase, the cell size in the brain by removing ﬂuid from the intracellular space.

Choice C Reason: This is incorrect because an osmotic diuretic would decrease, not expand, the extracellular ﬂuid volume by increasing the urine output and excreting excess ﬂuid from the body.

Choice D Reason: This is incorrect because an osmotic diuretic would not provide ﬂuid hydration, but rather cause ﬂuid loss and dehydration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic eﬀect?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreﬂexia. Which of the following actions should the nurse take first?

A nurse is monitoring the ﬂuid replacement of a client who has sustained burns. The nurse should administer which of the following ﬂuids in the first 24 hr following a burn injury?

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?

A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is eﬀective?

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?