Nokea
A client with a history of stroke is at risk for aspiration. Which of the following interventions should the nurse include in the plan of care? Select all that apply.
- A. Position the client upright during meals.
- B. Offer thin liquids to promote swallowing.
- C. Assess the client's gag reflex before feeding.
- D. Provide small, frequent meals.
- E. Thicken liquids as needed.
Correct Answer: A, C, D, E
Rationale: Upright positioning, assessing gag reflex, small frequent meals, and thickened liquids reduce aspiration risk. Thin liquids increase risk.
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A client with a history of breast cancer is prescribed anastrozole (Arimidex). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Anastrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.
A nurse is caring for a client who has undergone a total laryngectomy for laryngeal cancer. What information is important to include in his discharge teaching? Select all that apply.
- A. Providing humidity at home.
- B. Following a bland diet.
- C. Learning how to suction himself.
- D. Having communication rehabilitation with a speech pathologist.
- E. Attending a smoking cessation program.
Correct Answer: A,C,D,E
Rationale: After a total laryngectomy, the client needs humidity to keep the airway moist, must learn to suction the airway to maintain patency, requires speech rehabilitation to learn alternative communication methods, and should attend smoking cessation to reduce further risk. A bland diet is not typically required unless specified for other conditions.
A client with a history of chronic kidney disease is prescribed darbepoetin alfa (Aranesp). The nurse should monitor the client for which of the following side effects?
- A. Hypotension.
- B. Hypertension.
- C. Hypoglycemia.
- D. Weight loss.
Correct Answer: B
Rationale: Darbepoetin alfa can cause hypertension due to increased red blood cell production, requiring monitoring.
A client with a chronic mental illness who does not always take her medications is separated from her husband and receives Supplemental Security Income. She lives with her mother and older sister and manages her own medication. The client's mother is in poor health and receives Social Security benefits. The client's sister works outside the home, and the client's father is dead. Which of the following issues should the nurse need to address first?
- A. Family
- B. Marital
- C. Financial
- D. Medication
Correct Answer: D
Rationale: Medication non-adherence in a client with chronic mental illness is the priority issue, as it directly impacts mental stability and safety. Family, marital, and financial issues are secondary.
The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see fi gure). The nurse should:
- A. Wear a powered air purifying respirator (PAPR) face shield.
- B. Use goggles that include the hairline.
- C. Change to a surgical mask.
- D. Proceed to suction the client’s tracheostomy.
Correct Answer: D
Rationale: The nurse is wearing protective personnel equipment appropriately for suctioning the client: goggles, gown and respirator mask. It is not necessary to wear a powered air purifying respirator face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.