In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

Medical diagnoses.

Age and gender.

Developmental stage.

Functional capacity.

Answer and Explanation

The Correct Answer is D

A.   While medical diagnoses can influence the type of care a client needs, functional capacity is the most important factor when determining the best living environment.
B.   Age and gender can be factors to consider, but they are not as important as functional capacity. For example, an older adult with a high level of functional independence may be able to live independently, even if they are elderly.
C.   This is not relevant to the decision of where an older adult client should live.
D.   The client's functional capacity is the most important factor to consider when determining the best living environment. If the client requires significant assistance with ADLs, a nursing home or assisted living facility may be the most appropriate option.

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Correct Answer is B

Explanation

A. Measuring body temperature is important in assessing the client’s overall condition and identifying a fever, which is common in pneumonia. However, while it provides useful information about the client's status, it is not the most urgent action compared to interventions that could immediately impact the client’s respiratory function or confirm the diagnosis.
B. Administering PRN (as needed) oxygen is crucial if the client shows signs of hypoxia or difficulty breathing. If the client's face appears cyanotic or if they are experiencing respiratory distress, this action should be prioritized to ensure adequate oxygenation.
C. A chest x-ray is essential for diagnosing pneumonia and assessing the extent of lung involvement. However, while it is critical for diagnosis, addressing immediate respiratory needs and symptoms takes precedence.
D. Obtaining sputum for culture is important for identifying the causative organism and guiding antibiotic therapy. However, this action is less urgent than ensuring the client’s immediate respiratory needs are met and confirming the diagnosis through imaging.

A. Decrease the rate of the feeding by half. B. Observe for an allergic reaction to the formula. C. Hang a new bag of the enteral formula. D. Stop the tube feeding and assess the client.

Correct Answer is D

Explanation

A. Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B. While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C. Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D. Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

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In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with possible pneumonia. When entering the room, the nurse observes the client's face as seen in the picture. Which prescription should the nurse implement first?

Correct Answer is B

Explanation

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Correct Answer is D

Explanation

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