What findings should the nurse expect when assessing an older adult client?
Heightened sense of pain.
Increased nighttime sleeping.
Decreased sense of balance.
Nighttime urinary incontinence.
The Correct Answer is C
As people age, they may experience a decrease in their sense of balance. This can increase the risk of falls and injuries.
Choice A is wrong because older adults may actually have a decreased sense of pain.
Choice B is wrong because older adults may experience changes in their sleep patterns, including difficulty falling asleep or staying asleep.
Choice D is wrong because while urinary incontinence can be a common issue among older adults, it is not limited to nighttime.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Change the tubing set every 72 hr:Continuous enteral feeding tubing sets should generally be changed every 24 hours to reduce the risk of bacterial contamination. Changing every 72 hours is too long and increases infection risk.
B. Aspirate residual volume every 4 hr:Aspiration of residual volume every 4 hours is standard practice when providing continuous enteral feedings. This ensures the client is tolerating the feedings and helps prevent aspiration or overfeeding. Large residual volumes may indicate poor gastric emptying.
C. Flush the tubing with 10 mL of water every 2 hr:The tubing should be flushed with 30 mL of water every 4-6 hours (depending on protocol), not just 10 mL, to maintain tube patency and prevent clogging.
D. Heat the formula to 40.5° C (105° F):Formula should not be heated to such a high temperature. It should be administered at room temperature to avoid discomfort and potential damage to the gastrointestinal tract.
Correct Answer is D
Explanation
The nurse should place the extremity in a dependent position before inserting an IV catheter.
This helps to dilate the veins and make them more visible and easier to access.
Choice A is wrong because the nurse should choose a site that is distal to the most proximal site on the extremity selected.
This helps to preserve more proximal sites for future use if needed.
Choice B is wrong because applying a cool compress before insertion of an IV catheter can cause vasoconstriction and make it more difficult to access the vein.
Instead, a warm compress can be applied to help dilate the veins.
Choice C is wrong because the tourniquet should be placed above, not below, the proposed insertion site to help dilate the vein and make it easier to access.
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