A client with dysphagia is having difficulty swallowing medications. What is the nurse's best intervention?
- A. Crush the medications and mix them with applesauce.
- B. Encourage the client to drink water with each dose.
- C. Consult with the healthcare provider about switching to liquid medications.
- D. Offer the client soft foods to reduce difficulty swallowing.
Correct Answer: C
Rationale: The best intervention for a client with dysphagia experiencing difficulty swallowing medications is to consult with the healthcare provider about switching to liquid medications. Liquid medications are often easier to swallow and can reduce the risk of choking and aspiration in clients with dysphagia. Crushing medications can alter their effectiveness, encouraging the client to drink water may not be sufficient, and offering soft foods is not directly related to improving medication swallowing.
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A client with diabetes mellitus reports feeling shaky, dizzy, and sweaty. The nurse checks the client's blood glucose level and it is 55 mg/dL. What is the nurse's next action?
- A. Give the client a glucagon injection
- B. Encourage the client to eat a high-protein snack
- C. Administer 15 grams of a fast-acting carbohydrate
- D. Recheck the blood glucose level in 15 minutes
Correct Answer: C
Rationale: A blood glucose level of 55 mg/dL indicates hypoglycemia, which should be treated with a fast-acting carbohydrate to quickly raise the blood sugar. Administering 15 grams of a fast-acting carbohydrate, such as glucose tablets or juice, is the appropriate initial intervention for hypoglycemia. Giving a glucagon injection is reserved for severe cases or when the client is unconscious. Encouraging the client to eat a high-protein snack is not appropriate for treating acute hypoglycemia, as it is a slower-acting form of glucose. Rechecking the blood glucose level is important but should occur after providing immediate treatment to raise the blood sugar level.
A nurse is caring for a 73-year-old male client with Alzheimer's disease. Which action should the nurse take to enhance the client's nutritional intake?
- A. Encourage the client to eat large meals in one sitting.
- B. Offer the client frequent snacks of foods he enjoys.
- C. Provide the client with foods high in fiber to improve digestion.
- D. Discourage eating late at night to prevent weight gain.
Correct Answer: B
Rationale: Offering frequent snacks of foods the client enjoys is the most appropriate action to enhance the nutritional intake of a client with Alzheimer's disease. This approach helps to ensure that the client receives an adequate amount of nutrients throughout the day, especially when larger meals might be challenging for individuals with Alzheimer's. Encouraging large meals in one sitting (Choice A) may overwhelm the client and lead to decreased food intake. While foods high in fiber (Choice C) are beneficial for digestion, the primary focus should be on providing foods the client enjoys to increase intake. Discouraging eating late at night (Choice D) is not directly related to enhancing nutritional intake in this scenario.
The nurse administers an antibiotic for a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor?
- A. Platelet count and red blood cell count.
- B. White blood cell count and sputum culture.
- C. Hemoglobin A1c and glucose tolerance test.
- D. Arterial blood gases and serum electrolytes.
Correct Answer: B
Rationale: The correct answer is B: White blood cell count and sputum culture. Monitoring white blood cell count and sputum cultures is essential to assess the effectiveness of the antibiotic in treating the respiratory tract infection. Changes in white blood cell count can indicate the body's response to infection, while sputum cultures help determine if the antibiotic is targeting the specific pathogens causing the infection. Choices A, C, and D are incorrect because platelet count, red blood cell count, hemoglobin A1c, glucose tolerance test, arterial blood gases, and serum electrolytes are not directly related to evaluating the effectiveness of an antibiotic in treating a respiratory tract infection.
Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's care plan?
- A. Check platelet count
- B. Observe the color of urine
- C. Review liver function tests
- D. Monitor for bleeding
Correct Answer: D
Rationale: Prasugrel is a platelet inhibitor, which increases the risk of bleeding. Monitoring for bleeding, particularly at the catheterization site and in other areas, is the most important assessment following administration of the drug. Checking platelet count and observing urine color are relevant but not as immediate. Reviewing liver function tests is not directly related to the adverse effects of prasugrel.
The nurse is caring for a client with an indwelling urinary catheter. Which of the following actions should the nurse prioritize to prevent infection?
- A. Maintain a closed drainage system
- B. Cleanse the catheter insertion site daily
- C. Increase the client's fluid intake
- D. Empty the collection bag every 4 hours
Correct Answer: A
Rationale: The correct answer is to maintain a closed drainage system. This action is crucial in preventing infection as it helps prevent bacteria from entering the urinary tract. While cleansing the catheter insertion site and ensuring adequate hydration are important aspects of catheter care, the top priority is maintaining the integrity of the closed system to prevent infection. Emptying the collection bag regularly is also important but not as critical as ensuring a closed drainage system to minimize infection risk.