Nokea
A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?
- A. drowsiness
- B. complaint of nausea
- C. pulse rate of 92
- D. restlessness
Correct Answer: D
Rationale: Restlessness is often a sign of respiratory distress or secretion build-up, indicating the need for suctioning. While drowsiness (choice A) can be a sign of hypoxia, it is not as immediate an indication for suctioning as restlessness. Complaint of nausea (choice B) and a pulse rate of 92 (choice C) are not directly related to the need for suctioning in a client on a volume-cycled ventilator.
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A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?
- A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
- B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate.
- C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
- D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.
Correct Answer: A
Rationale: The most crucial point to reinforce to the patient after a vasectomy is the need for continued contraception until it is confirmed that the ejaculate is sperm-free. Choice A emphasizes this by highlighting the importance of using another form of contraception until the healthcare provider confirms the absence of sperm. This is essential to prevent unintended pregnancies. Choices B, C, and D do not address the key point of ensuring contraception until sperm absence is confirmed and are therefore not as important to reinforce in this scenario.
A nurse is contributing to the plan of care of a client who has had a stroke. The client is experiencing severe dysphagia with choking and coughing while eating. Which of the following nutritional therapies should the nurse expect to include in the plan of care?
- A. NPO until dysphagia subsides
- B. Supplements via NG tube
- C. Initiation of total parenteral nutrition
- D. Mechanical soft diet
Correct Answer: D
Rationale: The correct answer is D: Mechanical soft diet. A mechanical soft diet is appropriate for clients with severe dysphagia as it helps reduce the risk of choking and aspiration by providing food that is easier to swallow. Choice A, NPO until dysphagia subsides, may be necessary initially but is not a long-term solution. Choice B, supplements via NG tube, may be considered if the client is unable to meet their nutritional needs orally, but it does not address the texture modification needed for dysphagia. Choice C, initiation of total parenteral nutrition, is typically reserved for clients who cannot tolerate any oral intake and is not the first-line option for dysphagia management.
A nurse is assisting with the development of an education program for a community group about intake of vitamins and minerals in the diet. Which of the following foods should the nurse recommend as the best source of vitamin C?
- A. ½ cup green pepper
- B. 1 medium orange
- C. ½ cup cabbage
- D. 1 medium tomato
Correct Answer: B
Rationale: The correct answer is B: 1 medium orange. Oranges are well-known for being rich in vitamin C, an essential nutrient for immune function and skin health. While choices A, C, and D also contain some vitamin C, the medium orange provides a higher amount of this vitamin compared to a ½ cup of green pepper, ½ cup of cabbage, or a medium tomato.
The nurse is caring for a client post appendectomy. The client has developed a fever, and the incision site is red and swollen. Which of these assessments is a priority for the nurse to perform?
- A. Check the client's blood pressure
- B. Assess the client's pain level
- C. Inspect the incision site
- D. Monitor the client's respiratory status
Correct Answer: C
Rationale: Inspecting the incision site is a priority in this situation because the redness and swelling indicate a potential infection. This assessment helps the nurse determine the extent of infection and the appropriate intervention, such as administering antibiotics or notifying the healthcare provider. Checking the client's blood pressure (Choice A) may be important but is not the priority in this scenario where signs of infection are present. Assessing the client's pain level (Choice B) is also important but addressing the infection takes precedence. Monitoring the client's respiratory status (Choice D) is essential but not the priority when dealing with a localized infection at the incision site.
A nurse is reinforcing teaching to transition from breastfeeding to whole milk with the parents of an infant. Which of the following months of age should the nurse recommend for transitioning the infant to whole milk?
- A. 6 months
- B. 8 months
- C. 10 months
- D. 12 months
Correct Answer: D
Rationale: The correct answer is D: 12 months. Whole milk should be introduced at 12 months to ensure the infant's digestive system can handle the increased fat content. Introducing whole milk before 12 months can lead to digestive issues and potential allergies. Choices A, B, and C are incorrect because transitioning to whole milk before 12 months is not recommended for infants due to their digestive system still developing and not being able to handle the higher fat content of whole milk.