A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide?

"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."

Clients over the age of 65 must have a saline lock according to facility policy."

"It is quicker to administer medications intravenously in the hospital."

"We administer all medications intravenously to clients in this unit.

Answer and Explanation

The Correct Answer is A

A. "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours.": This response directly explains the medical reason for the saline lock, linking it to the client’s prescribed therapy. It provides clarity and reinforces that the intervention is necessary for safe and effective treatment.

B. "Clients over the age of 65 must have a saline lock according to facility policy.": Age alone is not a valid reason for IV access. Using such an explanation could reduce trust between the nurse and the client.

C. "It is quicker to administer medications intravenously in the hospital.": While IV administration can be faster, this response is vague and does not address why this particular client specifically requires a saline lock. It lacks individualized rationale.

D. "We administer all medications intravenously to clients in this unit.": Not all medications are given intravenously. Providing this explanation would confuse the client and reflect poor communication of actual care needs.

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Correct Answer is B

Explanation

A. Stridor: Stridor is a harsh, high-pitched sound heard primarily during inspiration and is usually caused by upper airway obstruction, such as laryngeal edema or foreign body aspiration. It is not typically associated with asthma exacerbations.

B. Wheezes: Wheezes are continuous, high-pitched, musical sounds most often heard during expiration, caused by narrowing of the lower airways due to bronchospasm or inflammation. They are a hallmark finding in clients with asthma.

C. Crackles: Crackles are intermittent, non-musical sounds heard during inspiration and are caused by fluid, mucus, or collapsed alveoli popping open. They are more commonly associated with pneumonia, heart failure, or pulmonary fibrosis.

D. Rhonchi: Rhonchi are low-pitched, coarse, snoring-like sounds caused by secretions or obstruction in the larger airways. They often clear with coughing and are not the typical finding in asthma.

A. Have the client move each limb independently through its complete range of motion. B. Ask the client to move her arms and legs while applying slight resistance. C. instruct the client to tighten muscle groups for a short period, and then relax D. Move the client's limbs through their complete range of motion.

Correct Answer is C

Explanation

A. Have the client move each limb independently through its complete range of motion: This describes active range of motion exercises, which involve joint mobility but do not focus on muscle strengthening through tension as isometric exercises do.

B. Ask the client to move her arms and legs while applying slight resistance: This describes isotonic resistance exercises, where movement occurs against an external force. Isometric exercises, in contrast, involve no visible joint movement.

C. Instruct the client to tighten muscle groups for a short period, and then relax: Isometric exercises involve contracting muscles without moving the associated joint. This action maintains muscle strength and circulation during bedrest, reducing the risk of deconditioning.

D. Move the client's limbs through their complete range of motion: This describes passive range of motion, which maintains joint flexibility but does not engage the client’s muscles actively. It does not provide the benefits of isometric strengthening.

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A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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