A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A)   A 79 year-old malnourished client on bed rest B)   An obese client who uses a wheelchair C)   A client who had 3 incontinent diarrhea stools D)   An 80 year-old ambulatory diabetic client The correct answer is A: A 79 year-old malnourished client on bed rest 75. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse’s priority? A)   Obtain a complete blood count B)   Obtain a health and dietary history C)   Refer to a provider for a physical examination D)   Measure height and weight The correct answer is B: Obtain a health and dietary history 76. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A)   Abdominal x-ray B)   Auscultation C)   Flushing tube with saline D)   Aspiration for gastric contents The correct answer is A: Abdominal x-ray 77. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? A)   Allow the client to melt ice chips in the mouth B)   Provide mints to freshen the breath C)   Perform frequent oral care with a tooth sponge D)   Swab the mouth with glycerin swabs The correct answer is C: Perform frequent oral care with a tooth sponge 78. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A)  Exercise doing weight bearing activities B)  Exercise to reduce weight C)  Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones The correct answer is A: Exercise doing weight bearing activities 79. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? A)   Cheese sandwich with a glass of 2% milk B)   Sliced turkey sandwich and canned pineapple C)   Cheeseburger and baked potato D)   Mushroom pizza and ice cream The correct answer is B: Sliced turkey sandwich and canned pineapple 80. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? A)  All 4 side rails up, wheels locked, bed closest to door B)  Lower side rails up, bed facing doorway C)  Knees bent, head slightly elevated, bed in lowest position D)  Bed in lowest position, wheels locked, place bed against wall The correct answer is D: Bed in lowest position, wheels locked, place bed against wall 81. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A)   Every four to six hours B)   Continuously