An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vagina tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?

Voiding after intercourse to reduce infection.

Need for scheduling annual well woman exams.

The importance of using vaginal lubricants.

Intercourse positions that can help prevent tears.

Answer and Explanation

The Correct Answer is C

A.   While voiding after intercourse can help reduce the risk of urinary tract infections (UTIs), it is not directly related to preventing vaginal tears. This practice is more relevant for preventing infections rather than addressing the issue of tissue trauma or dryness that may lead to tearing.
B.   Regular well-woman exams are important for overall gynecological health and early detection of potential issues, but they do not directly address the immediate concern of preventing vaginal tears during intercourse.
C.   Vaginal dryness is a common issue in older women, often due to decreased estrogen levels. Dryness can make vaginal tissues more susceptible to tearing during intercourse. Using vaginal lubricants can help reduce friction and prevent tears, making this the most relevant and practical advice for the client in this situation.
D.   While certain positions may be more comfortable and could potentially reduce the risk of tearing, this advice is secondary to addressing the fundamental issue of vaginal dryness. Focusing on lubrication provides a more direct and effective approach to preventing tears.

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Correct Answer is A

Explanation

A.Potassium affects the electrical activity of the heart, and abnormal potassium levels can lead to serious cardiac arrhythmias or other complications. Continuous cardiac monitoring is crucial when administering potassium chloride because it helps detect any arrhythmias or changes in heart function that might be caused by changes in potassium levels.
B.Monitoring urinary output is important because adequate urine output helps assess kidney function and ensures that potassium is being excreted properly. While monitoring urinary output is important, it is secondary to immediate cardiac monitoring during the infusion.
C.Checking the serum potassium level after the infusion is important to confirm that potassium levels have normalized or stayed within the target range. However, this action is not as immediate as continuous cardiac monitoring during the infusion.
D.Regular monitoring of vital signs is important to assess overall client stability and detect any systemic changes. However, obtaining vital signs every 2 hours might not be as critical as continuous cardiac monitoring when administering potassium.

A. Gather a history from adult child about circumstances of previous falls. B. Inform the adult child that fall prevention is a priority for older adults. C. Ask the adult child to remain with the client during the examination. D. Encourage the adult child to report the incident to other siblings.

Correct Answer is A

Explanation

A. Understanding the circumstances of previous falls can help identify any risk factors that may have contributed to the current fall. This information can be used to develop a plan to prevent future falls. By gathering information about previous falls, the nurse can develop a more comprehensive plan to address the client's specific needs and reduce the risk of future falls.
B. While it's important to educate the adult child about fall prevention, gathering information about previous falls is a more immediate priority.
C. Asking the adult child to remain with the client is appropriate, but it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.
D. While informing other family members may be important, it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.

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An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vagina tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

Correct Answer is A

Explanation

An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?

Correct Answer is A

Explanation

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?