Nokea
A client is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?
- A. Administer antihypertensives as prescribed.
- B. Check the client's weight daily.
- C. Notify the provider if the urine output is less than 30 mL/hr.
- D. Encourage the client to ambulate independently four times a day.
Correct Answer: B
Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.
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The LPN/LVN is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which observation indicates that the client is experiencing oxygen toxicity?
- A. Nasal congestion
- B. Cough
- C. Sore throat
- D. Fatigue
Correct Answer: C
Rationale: The correct answer is 'C: Sore throat.' Oxygen toxicity can manifest with symptoms like a sore throat, cough, chest pain, difficulty breathing, and fatigue. However, a sore throat can be an early indicator of oxygen toxicity and should prompt immediate attention. Nasal congestion, cough, and fatigue are not specific indicators of oxygen toxicity but could be related to other factors in a client with COPD receiving oxygen therapy.
A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?
- A. Dietitian consult
- B. Speech therapy referral
- C. Oral suction at the bedside
- D. Clear liquids
Correct Answer: D
Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids or pureed foods. Therefore, the nurse should clarify the prescription for clear liquids to prevent potential harm to the client. Choices A, B, and C are appropriate interventions for a client with dysphagia following a stroke. A dietitian consult can help modify the client's diet for safe swallowing, speech therapy can assist in improving swallowing function, and oral suction at the bedside helps maintain airway patency and prevents aspiration.
The nurse is caring for an older adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?
- A. Encourage the patient to perform as many self-care activities as possible.
- B. Provide assistance with a bed bath to promote patient comfort.
- C. Coordinate with physical therapy for gait training.
- D. Instruct the patient to remain on bed rest to prevent fatigue.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to perform as many self-care activities as possible. For a patient who has had a stroke, promoting independence and engaging in self-care activities help maintain mobility and foster a sense of autonomy. Choices B, C, and D are incorrect because providing assistance with a bed bath, coordinating with physical therapy for gait training, or advising bed rest without indications may not be the best interventions for promoting optimal recovery and independence in a stroke patient.
A healthcare professional working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during their shift. Which of the following signatures may the healthcare professional legally witness?
- A. A 16-year-old client who is married
- B. A 27-year-old who has schizophrenia
- C. An adoptive parent who brings in their 8-year-old child
- D. A 17-year-old mother who brings in her toddler
Correct Answer: A
Rationale: The correct answer is A. A 16-year-old who is married can legally sign an informed consent form. In this case, being married at 16 may indicate legal emancipation or the ability to consent to medical treatment. Choice B is incorrect because having schizophrenia doesn't automatically imply incapacity to provide informed consent. Choice C is incorrect as an adoptive parent does not have the legal authority to provide consent for medical treatment on behalf of a child without proper documentation. Choice D is incorrect as a 17-year-old mother would generally not have the legal capacity to give consent for her toddler, as parental consent is usually required for minors.
A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?
- A. Establish goals that are measurable and realistic.
- B. Set goals that are a little beyond the capabilities of the patient.
- C. Use the nurse's own judgment and not be swayed by family desires.
- D. Explain that without taking alignment risks, there can be no progress.
Correct Answer: A
Rationale: When developing an individualized plan of care for a patient, the nurse must set goals that are specific, measurable, achievable, realistic, and time-bound (SMART). Choice A is correct as it emphasizes the importance of establishing goals that are measurable and realistic, ensuring they are attainable within a specific timeframe. Setting goals that are beyond the capabilities of the patient (Choice B) can lead to frustration and lack of progress. Using only the nurse's judgment and disregarding family desires (Choice C) may not consider important aspects of the patient's social support and preferences. Explaining that progress requires taking alignment risks (Choice D) is not a standard approach in nursing care planning and may confuse the patient or hinder trust in the nurse's decision-making.