A nurse is caring for an older client on a medical-surgical unit.Which of the following interventions should be included in the plan of care?
Monitor the client’s hydration status.
Encourage the client to engage in physical activities.
Administer medications as prescribed.
Educate the client on dietary needs.
The Correct Answer is A
Choice A rationale
Monitoring the client’s hydration status is critical for older adults, especially those on a medical-surgical unit, to prevent dehydration, which can lead to serious complications such as renal impairment, confusion, and electrolyte imbalance.
Choice B rationale
Encouraging physical activities is beneficial but is not always feasible or safe for all older clients, especially those with certain medical conditions or mobility limitations.
Choice C rationale
Administering medications as prescribed is essential but is a standard practice for all clients and not specific to older adults' unique needs.
Choice D rationale
Educating the client on dietary needs is important but secondary to monitoring hydration, which addresses more immediate physiological needs and complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Choice A rationale:
The client's low platelet count (90 x 10⁹/L) is a significant risk factor for developing Disseminated Intravascular Coagulation (DIC), a condition characterized by abnormal blood clotting and bleeding. The client's history of cancer and symptoms such as unexplained bruising and fatigue further support this risk.
Choice B rationale:
Hyperkalemia is characterized by high potassium levels, but the client's potassium level is within the normal range (4.1 mmol/L), so this is not a risk factor.
Choice C rationale:
Hyponatremia is a condition of low sodium levels in the blood. The client's sodium level is normal (137 mmol/L), so this is not a risk factor.
Choice D rationale:
Pneumonia is a lung infection, and the client's oxygen saturation is normal (98% on room air), indicating no immediate risk of pneumonia.
Choice E rationale:
Acute nephritic syndrome is a kidney disorder that can cause elevated blood urea nitrogen (BUN) and creatinine levels. The client's BUN is slightly elevated (22 mg/dL), but her creatinine level is normal (1.0 mg/dL), making this less likely.
Correct Answer is C
Explanation
Choice A rationale
The client's complete blood count does not specifically indicate an increased risk for bleeding. Platelet levels would need to be evaluated for bleeding risk.
Choice B rationale
Erythropoiesis stimulating agents are used for anemia but are not indicated based on the provided CBC.
Choice C rationale
The client is at increased risk of infection due to low white blood cell count (leukopenia), which indicates immunosuppression.
Choice D rationale
While a high-protein diet is beneficial during cancer treatment, the CBC results highlight an infection risk as the primary concern.
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