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.

Answer and Explanation

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.

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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.

A. The medication works by decreasing gastric acid secretions. B. The medication relieves nausea by slowing peristalsis. C. The medication works by relaxing gastric muscles. D. The medication relieves nausea by promoting gastric emptying.

Correct Answer is D

Explanation

Choice A rationale
Metoclopramide does not work by decreasing gastric acid secretions. It is not classified as an antacid or acid suppressant.
Choice B rationale
Metoclopramide does not relieve nausea by slowing peristalsis. In fact, it increases peristalsis, which helps move contents through the gastrointestinal tract more quickly.
Choice C rationale
Metoclopramide does not work by relaxing gastric muscles. Instead, it enhances the tone and motility of the gastrointestinal tract.
Choice D rationale
Metoclopramide relieves nausea by promoting gastric emptying. It increases the movement of the stomach and intestines, which helps reduce feelings of nausea and vomiting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4 hours as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which of the following explanations should the nurse provide?

Correct Answer is D

Explanation

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