Gerontology HESI Practice Correct and Verified Answers Graded A.

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Gerontology HESI Practice Correct and Verified Answers Graded A.

• The home health registered nurse (RN) is changing an older client's wet to dry

dressing. Which observation should the RN evaluate as a therapeutic response with the removal of the dry dressing? A. Debridement and removal of slough and eschar B.Drainage of purulent exudate from the wound C. Moist skin edges around the wound field

• Presence of capillary growth in the wound

Correct Answer: (A) Debridement and removal of slough and eschar Rationale: Wet to dry dressings begin with a wet packing inside of the wound, and then a dry gauze is used to cover the wet packing to wick drainage and bacteria away from the wound to promote healing. Removal of dried dressing provides debridement by removing exudate, sloughing tissue, and eschar (A). (B) is evidence of an infection. (C) is indicative of continuous moisture that is causing the skin edges of the wound to be vulnerable to further damage.(D) is manifested by a pink environment with serosanguineous fluid.

• An older male client is admitted to the hospital with left-sided heart failure (HF).

Which finding should the registered nurse (RN) document that is consistent with HF?

• Ascites B. Pitting edema C. Jugular distention D. Coarse and fine crackles

Correct Answer: (D) Coarse and fine crackles Rationale: In left-sided heart failure, the inadequacy of pumping blood into the aorta causes blood to back up into the pulmonary capillaries; this pushes intravascular fluid into the alveoli, which is manifested as crackles or rales. (A, B and C) are manifested in right-sided heart failure.

• After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly

client with chronic obstructive pulmonary disease (COPD) is admitted for pneumonia.The client has a long history of smoking and still smokes a pack of cigarettes a day.Which finding should the registered nurse (RN) report to the healthcare provider? A.Barrel chest with increased chest diameter B. Crackles and pulse oximetry level of 88% C.Low hemoglobin and hematocrit levels D. Arterial blood gases indicating respiratory acidosis

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Correct Answer: (B) Crackles and pulse oximetry level of 88% Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact adequate oxygenation, which should be reported to the HCP. (A) occurs due to chronic hyperinflation of the lungs and is common in clients with COPD. Anemia (C) is frequently identified in clients with COPD, and respiratory acidosis (D) due to CO2 retention contributes to a lower blood pH.

• An older female client recently moved to an assisted living facility. The family

explains to the registered nurse (RN) that the client is unmanageable and always confused, disoriented and depressed. The client asks the RN repeatedly, "Where am I?". How should the RN respond? A. Explain that she is in a new home called an assisted living community B. Question the client about her perception of where she might be now.

• Distract the client with a scenario that she is on an outing with her family. D. Reassure

the client not to worry because she will meet new friends.Correct Answer: (A) Explain that she is in a new home called an assisted living community.Rationale: Reality re-orientation (A) is the best response for a client who is confused because the response is consistent and true. (B, C, and D) do not provide the client with feedback that is reality based.

• A new resident in an assisted living facility is an older client who is experiencing

short-term memory loss and confusion. Which activity should the registered nurse (RN) schedule the client to do during the day? A. Arts and crafts B. Current events discussion group C. Group sing-along D. Daily exercise group Correct Answer: (D) Daily exercise group Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes the client's stress to remember. (A), (C), and a current events discussion group (B) are thought-provoking activities that require attention to detail and short-term memory to participate in the group activity which may be stressful and frustrating to the resident who has difficulty remembering sequence of the details.

• An older male client with heart failure (HF) complains of chronic constipation and

wants to retrain his bowel. Which information should the registered nurse (RN) offer the client for establishing regular bowel habits? A. Add whole grain foods and fibrous vegetables to diet B. Drink water and fluids up to 3,000 ml daily C. Use a stool softener or glycerin suppository PRN D. Plan daily exercise based on fatigue level Correct Answer: (A) Add whole grain foods and fibrous vegetables to diet. Rationale: Increasing daily fiber (A) with increasing fluid intake are the best tools to use when retraining bowel habits. (B) may cause fluid overload for this older client and potentially exacerbate HF. (C) should not be advised without the healthcare provider's

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recommendation. The client's fatigue level may curtail how much daily exercise (D) the client can tolerate.

• An older female client who has been taking hydrocodone/acetaminophen (Lortab)

q4 hours for chronic back pain for the past 5 years tells the registered nurse (RN) that she cannot live without her pain pills. When asked if she is addicted, the client states that she is not an addict because the healthcare provider prescribed the pain pills.Which coping mechanism should the RN determine the client is using about her addiction? A. Lack of knowledge about narcotic medications B. Rationalization to support narcotic use C. Transfer of blame to healthcare provider D. Justification of narcotic use due to chronic pain Correct Answer: (B) Rationalization to support narcotic use. Rationale: The client is using rationalization to maintain self-esteem when she is questioned by stating that she is not addicted because she is taking medication prescribed by a healthcare provider. (A) may be possible, but the client is being specifically asked about possible addiction. (C) and (D) underlie the complexity of denial in addiction, but the client is trying to maintain self- esteem through rationalization.

• An older male client is admitted for emergency treatment of acute closed-angle

glaucoma. The registered nurse (RN) begins administering the prescribed miotic medications and glycerin (Glycol) therapy. Which intervention is most important for the RN to maintain during the client's therapy? A. Maintain lighting control in the room during therapy B. Monitor intake and output q2 hours for 24 hours C. Place an eye patch over the affected eye during sleep D. Administer the eye drops at the scheduled intervals Correct Answer: (B) Monitor intake and output q2 hours for 24 hours Rationale: Monitoring intake and output (B) is most important during the administration of glycerin (Glycol) due to the rapid acting osmotic diuretic effect of glycerin therapy. (A, C and D) are components of care, but the most important action during glycerin administration is evaluation of output.

• The registered nurse (RN) is assigned the care of an older client who returns to the

unit after surgery for closed angle glaucoma. What intervention in the plan of care should the RN bring to the attention of the healthcare team? A. Assist with ambulating to commode B. Monitor intake and output q8 hours C. Administer morphine 4 mg IM q2 hour PRN pain D. Place an eye patch on operative eye during sleep Correct Answer: (C) Administer morphine 4 mg IM q2 hour PRN pain Rationale: Morphine side effects include nausea, vomiting and constipation, causing straining on stool, all of which can increase intraocular pressure and cause intraocular bleeding during the postoperative period. Administration of morphine 0.4 mg IM q2 hours PRN pain (C) should

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be discussed with the healthcare team to determine the risk of the side effects for the client. (A), (B) and (D) are interventions that do not place the client at risk.

• The home health registered nurse (RN) is reinforcing instructions to the family

about how to prevent pressure ulcers for their older family member who is bedridden.Which measure should the RN discuss? A. Lift the client when turning instead of sliding

• Massage directly over reddened sites C. Change client's position every 4 hours D. Place

pillows under both the knees Correct Answer: (A) Lift the client when turning instead of sliding Rationale: Lifting instead of sliding (A) decreases chances of friction and shearing while moving the client. (B) is not recommended for tissue that show signs of early pressure, such as a stage 1 site. (D) does not reduce risk for pressure ulcers. Reposition q2 hours, not q4 hours (C), provides the most benefit in reducing pressure ulcer formation.

• The home health registered nurse (RN) is assessing an older client for a pressure

ulcer. Which finding should the RN observe the area for a Stage I pressure ulcer? A.Superficial skin breakdown and flaking B. Deep pink, red or mottle skin C. Subcutaneous damage or necrosis D. Skin that blanches pink when pressed