The nurse is assessing an elderly client who has become confused since admission to the hospital two days ago.
Which assessment should the nurse complete first?
Oxygen saturation measurement.
Review of current medications.
Intake and output last 24 hours.
Use of hearing aids or glasses.
The Correct Answer is A
This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.
Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.
Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.
Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.
Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.
The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.
Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Heat application increases blood flow and reduces muscle spasms, which can help relieve pain and promote healing. However, heat should not be applied for longer than 30 minutes at a time, as it can cause tissue damage and inflammation.
Choice A is wrong because maximum benefits do not occur within the first five minutes.
It takes time for heat to penetrate the tissues and cause vasodilation.
Choice C is wrong because the heat should not be left in place for at least one hour to be effective.
This can lead to burns, increased edema, and decreased blood flow.
Choice D is wrong because heat can not be left in place for as long as 12 hours without harmful effects.
This can cause severe tissue damage, infection, and necrosis.
Normal ranges for heat application are between 104°F and 113°F (40°C and 45°C).
The temperature should be checked frequently and adjusted according to the patient’s comfort and tolerance.
The skin should also be inspected for signs of erythema, blisters, or burns.
Correct Answer is B
Explanation
This is because non-steroidal anti-inflammatory drugs (NSAIDs) are medicines that are used to treat rheumatoid arthritis by reducing pain, inflammation, and swelling.
However, NSAIDs do not slow down the disease progression or prevent joint
damage. Therefore, they are often used along with other types of medications, such as methotrexate or biologics, that can modify the disease course. NSAIDs may take up to two weeks to reach their full anti-inflammatory effect.
Choice A is wrong because using aspirin to relieve other types of pain can increase the risk of bleeding and stomach ulcers when taken with NSAIDs.
Choice C is wrong because taking the medication on an empty stomach can increase the risk of stomach irritation and ulcers.
Choice D is wrong because taking the medication after exercising does not prevent the progression of disease or joint damage.
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