HESI RN GERIATRICS EXAM 2020 After a transurethral resection of the prostate (TURP), an older man returns to the
medical surgical floor with a
... [Show More] 3-way indwelling urinary catheter. The registered nurse
(RN) observes the catheter's tubing for drainage when the client states that he needs to
void. What should the RN implement based on this finding?
A. Irrigate the bladder through the catheter port
B. Remove the indwelling catheter
C. Explain that urgency is expected
D. Notify the healthcare provider of the symptom –
(A) Irrigate the bladder through the catheter port
Rationale: The feeling of urgency can be caused by blood clots that can occlude
drainage of the catheter, which is a common occurrence in the first 72 hours after a
TURP. The urgency is an indication that the client's bladder is not emptying, and the
RN should irrigate catheter (A) to relieve symptoms caused by a clot. (B) and (C) should
not be implemented. (D) should be implemented after determining if the irrigation was
effective in relieving the client's complaint.
An older client with chronic kidney disease (CKD) has an arteriovenous fistula (AV) in
the left forearm for for hemodialysis. After palpating the AV fistula, which finding is an
indication that the AV fistula is functioning properly?
A. Enlarged veins
B. Redness around the site
C. Decreased pulses below fistula
D. Marked ecchymotic areas –
(A) Enlarged veins
Rationale: The mixing of arterial and venous blood in an AV fistula causes the veins to
enlarge (A), which facilitate cancelation for hemodialysis. (B) may be related to local
infection or inflammation and is not a normal finding. (C) and (D) are abnormal
findings that should be reported immediately.
During the quarterly evaluations of the clients in the assisted living community, the
registered nurse (RN) assesses for findings of failure to thrive in the older population.
What findings should the RN document and report as manifestations related to failure
to thrive? (Select all that apply.)
A. Unintentional weight loss
B. Increased weakness
C. Increased amounts of sleep
D. Irritation and agitation
E. Seeking constant attention from caregiver –
(A) Unintentional weight loss
(B) Increased weakness
(C) Increased amounts of sleep
Rationale: (A, B and C) are correct. Symptoms of failure to thrive in the older
population include weight loss, weakness and excessive sleep, which should be
documented and evaluated by a healthcare provider immediately. (D and E) are not
usual signs and symptoms of failure to thrive but should be reviewed by the healthcare
provider.
The registered nurse (RN) is reinforcing discharge instructions to the family of an older
client with failure to thrive. What information should the RN include to promote
nutritional intake for the client? (Select all that apply.)
A. Minimize stress levels by providing the client with a quiet environment during
meals
B. Provide food variations that the client can manage without assistance
C. Assist the client with eating meals in bed in a semi-Fowler's position
D. Encourage fluid intake before meals to decrease dehydration
E. Offer any type of food to the client as long as calories are consumed –
(A) Minimize stress level by providing the client with a quiet environment during
meals
(B) Provide food variations that the client can manage without assistance
Rationale: (A and B) are correct and continue to promote independence and decreased
stress for the client, which will increase the opportunity for nutritional intake. (C)
increases dependence for the older client, which can also cause decreased self-worth
and depression. (D) will make the client feel full and will decrease the client's ability to
consume nutritional calories. [Show Less]