Nokea
A client with dysphagia is ready to eat lunch. Which of these foods on the tray would be best to start with when assisting the client?
- A. diced fruit
- B. apple juice with a liquid thickener
- C. Jell-O™
- D. toast
Correct Answer: B
Rationale: A client with dysphagia is at risk for aspiration. A liquid thickener will allow the LPN to assess the client's ability to swallow prior to introducing pureed or solid foods. Since Jell-O™ melts into a clear liquid, it should not be used when assessing swallowing ability.
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The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these would be an appropriate action taken by the nurse?
- A. Inform the client that ear pain may occur and is normal.
- B. Provide ice water and a straw to promote easy fluid consumption.
- C. Provide hot tea to soothe the throat.
- D. Monitor vitals every 15 minutes.
Correct Answer: A
Rationale: Referred pain in the ear is normal after a tonsillectomy because of related nerve pathways. Vitals should be monitored every 15 minutes in the immediate postoperative period and then every 4 hours thereafter. Straws and hot beverages should be avoided as they may irritate the throat and disturb healing.
Pulling is easier than pushing. So pulling a client rather than pushing him or her has which of the following advantages?
- A. Reduces workload
- B. Decreases opposition from gravity
- C. Maintains stability
- D. Prevents muscle strain
Correct Answer: A
Rationale: Pulling reduces workload by working with gravity, lowering the effort needed compared to pushing against it.
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:
- A. notify the physician of the drainage.
- B. change the dressing.
- C. reinforce the dressing.
- D. apply an abdominal binder.
Correct Answer: C
Rationale: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.
In managing nausea related to Morphine epidural analgesia, the nurse should administer:
- A. Indocin
- B. Codeine
- C. Motrin
- D. Compazine
Correct Answer: D
Rationale: Compazine (prochlorperazine) is an antiemetic effective for opioid-induced nausea, unlike the other options, which are analgesics or anti-inflammatories.
The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?
- A. The application of moist heat will alter tissue sensitivity by producing numbness.
- B. The application of moist heat will decrease the metabolic needs of the involved tissues.
- C. The application of moist heat will stop the local release of histamine in the tissues.
- D. The application of moist heat will increase blood flow and accelerate tissue healing.
Correct Answer: D
Rationale: D: Warm compresses increase blood flow, promoting healing. A: Cold causes numbness. B: Heat increases metabolic needs. C: Cold reduces histamine release.