A nurse is caring for a 75-year-old client with aspiration pneumonia. The nurse should recognize what age-related change can contribute to the development of aspiration pneumonia?

Degenerative joint changes

Decreased gastric secretions

Decreased sense of smell

Diminished cough reflex

Answer and Explanation

The Correct Answer is D

A: Degenerative joint changes can affect mobility and overall health but do not directly contribute to aspiration pneumonia.

B: Decreased gastric secretions can affect digestion but are not a primary factor in the development of aspiration pneumonia.

C: A decreased sense of smell can affect appetite and food intake but does not directly lead to aspiration pneumonia.

D: A diminished cough reflex is a significant age-related change that can contribute to the development of aspiration pneumonia. The cough reflex helps clear the airway of food, liquid, and other foreign materials. When this reflex is diminished, the risk of aspiration and subsequent pneumonia increases.

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Correct Answer is A

Explanation

A: Checking the display on the PCA pump is the first action the nurse should take. This ensures that the pump is functioning correctly and delivering the prescribed dose of medication. It helps identify any technical issues that may be affecting pain control.

B: Obtaining an order for another pain medication for breakthrough pain is important if the current regimen is insufficient. However, this should follow the initial assessment of the PCA pump’s functionality.

C: Administering a bolus of medication may be necessary if the client is experiencing severe pain, but it should be done after confirming that the PCA pump is working correctly.

D: Encouraging the client to administer a demand dose is appropriate if the PCA pump is functioning correctly. However, the nurse should first verify that the pump is delivering the medication as prescribed.

A. Request the risk manager obtain consent for HIV testing from the client. B. Complete an incident report. C. Wash the site of injury with soap and water. D. Consent to post-exposure treatment with antiretroviral medications.

Correct Answer is C

Explanation

A: Requesting the risk manager to obtain consent for HIV testing from the client is important but should not be the first action. Immediate steps to reduce the risk of infection are more urgent.

B: Completing an incident report is necessary for documentation and follow-up but is not the immediate priority following a needle stick injury.

C: Washing the site of injury with soap and water is the first and most immediate action. This helps to reduce the risk of infection by removing any potential contaminants from the wound.

D: Consenting to post-exposure treatment with antiretroviral medications is important if there is a risk of HIV exposure. However, this should follow the initial step of cleaning the wound.

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A nurse is caring for a 75-year-old client with aspiration pneumonia. The nurse should recognize what age-related change can contribute to the development of aspiration pneumonia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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