when evaluating the temperature of older adults the nurse would remember which aspect about an older adults body temperature

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. When evaluating the temperature of older adults, what aspect should the healthcare provider remember about an older adult's body temperature?

A. The body temperature of the older adult is lower than that of a younger adult.
B. An older adult's body temperature is approximately the same as that of a young child.
C. Body temperature varies based on the type of thermometer used.
D. In older adults, body temperature can fluctuate widely due to less effective heat control mechanisms.

Correct answer: A

Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2�C. Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child. Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used. Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.

2. A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?

A. Administer the feeding as ordered
B. Pull the feeding tube out approximately 3 cm
C. Flush the feeding tube with 60 cc of water
D. Contact the physician

Correct answer: A

Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.

3. When educating a client about their new prescription for warfarin, what should the nurse advise?

A. To have his white blood cell count tested once a month
B. To avoid any activities that could lead to injury
C. To avoid eating leafy green vegetables
D. Both A and B

Correct answer: B

Rationale: The correct answer is to advise the client to avoid any activities that could lead to injury when taking warfarin. Warfarin is an anticoagulant medication that decreases blood clotting, increasing the risk of bleeding. Engaging in activities that may result in injury can lead to uncontrolled bleeding, which can be serious. While monitoring white blood cell count is not specifically related to warfarin therapy, avoiding leafy green vegetables is important due to their vitamin K content, which can interfere with warfarin's effectiveness. Therefore, the client should be educated to avoid activities that could cause injury to prevent potential bleeding complications.

4. What does the medical term 'basophilia' refer to?

A. An attachment of the epithelial cells of the skin to a basement membrane
B. An overabundance of a particular white blood cell in the peripheral blood
C. An underrepresentation of basophils on a blood smear
D. None of the above

Correct answer: B

Rationale: The correct answer is 'An overabundance of a particular white blood cell in the peripheral blood.' Basophilia specifically indicates an increased number of basophils in the peripheral blood. It can be observed in conditions like leukemia and certain allergic reactions. Choice A is incorrect as it describes something unrelated to basophilia. Choice C is incorrect as it suggests a decrease in basophils, which is opposite to the actual meaning of basophilia. Choice D is also incorrect as basophilia does have a defined medical significance.

5. Specific gravity in urinalysis:

A. compares the concentration of urine to that of distilled water
B. is useless when the patient is dehydrated
C. can only be measured using a refractometer
D. None of the above

Correct answer: A

Rationale: Specific gravity in urinalysis measures the concentration of solutes in urine compared to that of distilled water. This comparison helps in assessing the kidney's ability to concentrate urine properly. It is a valuable test even in dehydrated patients as it provides insights into renal function. Specific gravity can be measured using various methods, including a refractometer or reagent strips. Normal specific gravity readings of human urine typically range from 1.005 to 1.030. Choice A is correct as it accurately describes the purpose of specific gravity in urinalysis. Choices B and C are incorrect as specific gravity remains relevant in dehydrated patients and can be measured using different techniques, not solely a refractometer.