the nurse is caring for an elderly client and providing education which of the following would be least appropriate
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. When caring for an elderly client and providing education, which of the following would be the least appropriate for the nurse to do?

Correct answer: A

Rationale: Speaking loudly is inappropriate when caring for an elderly client. It is essential to assess the client for a hearing impairment and provide appropriate assistance if needed. Elderly clients may require more time to process information due to slower reaction times, benefit from shorter sessions as they fatigue easily, and can absorb supplemental written resources effectively. Therefore, speaking loudly may not be conducive to effective communication and may not cater to the specific needs of the elderly client, unlike the other options provided.

2. The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?

Correct answer: B

Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.

3. The client has an order for an IV piggyback of Ceftriaxone 750mg in 50mL D5W to run over 30 minutes. What is the appropriate drip rate?

Correct answer: A

Rationale: To calculate the drip rate, you need to convert the time from minutes to hours. The formula is (Volume to be infused / Time for infusion in minutes) x (60 minutes / 1 hour). Substituting the values, (50 mL / 30 min) x (60 min / 1 hr) = 100 mL/hr. Therefore, the appropriate drip rate is 100 mL/hr. Choices B, C, and D are incorrect as they do not match the calculated drip rate. Option A, 100 mL/hr, is the correct drip rate for administering Ceftriaxone 750mg in 50mL D5W over 30 minutes.

4. When a client and their family are facing the end stage of a terminal illness, where might they be best served?

Correct answer: C

Rationale: When a client and their family are facing the end stage of a terminal illness, they are best served by Hospice. Hospice offers a more humanized alternative care for dying clients compared to hospitals, focusing on comfort and quality of life in the final stages of life. It provides a specialized interdisciplinary team of health care professionals who work together to manage client care. Choices A, B, and D are incorrect because a rehabilitation center focuses on physical therapy, an extended care facility provides long-term care for activities of daily living, and a crisis intervention center deals with immediate psychological or social crises, none of which cater to the specific needs of clients facing the end stage of a terminal illness.

5. The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?

Correct answer: B

Rationale: The correct answer is 'My child has recently taken a few steps but does not seem stable when standing.' By 18 months of age, children should have taken their first steps and stand well. If a child hasn't made progress by this age, a physical therapy evaluation may be necessary. It is normal for an 18-month-old to start using a spoon to eat. However, the use of two-word phrases is not typically expected until 2 years of age. Separation anxiety is a common developmental phase that typically occurs between 6 and 18 months, so it does not require immediate follow-up. Therefore, the statement about the child not being stable when standing raises a red flag and necessitates further evaluation.

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