A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)

Increased peripheral circulation

Increased saliva production

Increased constipation

Decreased muscle mass

Decreased cough reflex

Answer and Explanation

Correct Answer : C,D,E

Choice A Reason :

Increased peripheral circulation is incorrect. As people age, changes in the cardiovascular system can occur, but increased peripheral circulation isn't a common physiological change. In fact, aging might lead to reduced elasticity in blood vessels, potentially resulting in decreased circulation to some areas.

Choice B Reason:

Increased saliva production is incorrect: Saliva production doesn't usually increase with age. Instead, certain medications, medical conditions, or treatments might impact saliva production. Aging itself doesn't commonly cause an increase in saliva production; in fact, it can decrease due to changes in salivary glands.

Choice C Reason:

Increased constipation is correct. As individuals age, there can be changes in gastrointestinal motility and muscle tone, which can contribute to an increased likelihood of constipation.

Choice D Reason:

Decreased muscle mass is correct. Aging often leads to a natural decline in muscle mass and strength, known as sarcopenia, which can affect mobility and overall physical function.

Choice E Reason:

Decreased cough reflex is correct. With aging, the cough reflex might become less sensitive or effective, which can impact the ability to clear the airways efficiently.

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Correct Answer is A

Explanation

Choice A Reason:

Recheck the client's SaO2 level after having the client cough and clear their throat is correct. This action is crucial to ensure the accuracy of the SaO2 reading. Sometimes, minor obstructions or secretions in the airway can momentarily affect the oxygen saturation readings. Having the client cough and clear their throat may help improve the SaO2 readings by clearing any temporary blockages.

Choice B Reason:

Review the client's most recent SaO2 level in the medical record is incorrect. While reviewing the client's history is important, the immediate priority is to verify the current SaO2 level for accuracy before taking further action.

Choice C Reason:

Notify the charge nurse of the client's condition is incorrect. While it might eventually be necessary to inform other healthcare team members, the immediate action should focus on rechecking the SaO2 level to ensure the client's current oxygen saturation status.

Choice D Reason:

Check the client's medical records to see which medications were recently administered is incorrect. Knowing the client's recent medications is important for assessment, but it may not directly address the current situation of shortness of breath and low oxygen saturation. Rechecking the SaO2 level takes precedence in this acute situation.

A. A client receives burns from a heating pad. B. A client's visitor becomes dizzy and faints in the client's room. C. A client becomes disoriented and falls out of bed. D. A client reports being dissatisfied with the temperature of the meals provided.

Correct Answer is ["A","C"]

Explanation

Explanation

Choice A Reason:

A client receives burns from a heating pad is correct. Any injury or harm caused to a client due to a medical device or equipment should be documented in an incident report for evaluation and review to prevent future incidents.

Choice B Reason:

A client's visitor becomes dizzy and faints in the client's room is incorrect. While this event might prompt the nurse to provide immediate assistance and seek medical attention for the visitor, it doesn't typically fall under the purview of an incident report unless it results from an issue within the healthcare facility.

Choice C Reason:

A client becomes disoriented and falls out of bed is correct. Falls resulting in injury or harm to the client, especially due to disorientation, should be documented to assess potential preventive measures and ensure appropriate care.

Choice D Reason:

A client reports being dissatisfied with the temperature of the meals provided is incorrect. Client dissatisfaction with meal temperature is an important concern, but it's generally addressed through communication and service improvement rather than being documented in an incident report unless it poses a risk to the client's health (e.g., if the food was excessively hot, causing harm).

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A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

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