Nokea
A 49-year-old female suffered a stroke that resulted in dysphagia. The dietician orders a diet of dysphagia-pureed foods. Which of the following foods would be an appropriate choice?
- A. beef stew
- B. hard-boiled egg
- C. custard
- D. sliced peaches
Correct Answer: C
Rationale: Custard is smooth and pureed, suitable for a dysphagia diet. Other options pose choking risks due to texture.
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The nurse is performing discharge teaching to a client who is on isoniazid (INH). Which diet selection would let the nurse know that the teaching has been ineffective?
- A. Tuna casserole
- B. Ham salad sandwich
- C. Baked potato
- D. Broiled beef roast
Correct Answer: A
Rationale: Isoniazid can interact with tyramine-rich foods like tuna, causing adverse effects (e.g., hypertension). Selecting tuna casserole indicates ineffective teaching. The other foods are safe.
The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?
- A. Notifying the physician
- B. Performing tracheal suctioning
- C. Repositioning the client to the left side
- D. Rechecking the client's O2 saturation
Correct Answer: B
Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.
The nurse is reflecting on the client-nurse relationship. Which statement is correct regarding the orientation (introductory) phase of the relationship?
- A. identifying the client's strengths and limitations
- B. promoting the client's insight and perception of reality
- C. continuously evaluating progress toward the client's goals
- D. exploring feelings about the termination phase of the relationship
Correct Answer: A
Rationale: The orientation phase focuses on establishing trust and identifying the client’s strengths and limitations to guide care.
The client is diagnosed with multiple myloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
- A. Walk about a mile a day to prevent calcium loss.
- B. Increase the fiber in your diet.
- C. Report nausea to the doctor immediately.
- D. Drink at least eight large glasses of water a day.
Correct Answer: D
Rationale: Cyclophosphamide can cause hemorrhagic cystitis; adequate hydration (e.g., 8 glasses of water) helps prevent this.
A 15-year-old client was involved in an auto accident and requires emergency surgery to control bleeding, but both parents are out of town and unable to sign the consent form. Which of the following is the most appropriate action?
- A. The client signs the consent form.
- B. The parents give telephone consent with two witnesses listening.
- C. The parents give email consent.
- D. The physician operates without consent because of the emergency situation.
Correct Answer: D
Rationale: In an emergency where a minor requires life-saving surgery and parents are unavailable, the physician can proceed without consent (D) to save the client's life. Client consent (A), telephone consent (B), or email consent (C) are not appropriate in this urgent situation.