Nokea
A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, 'I don't know what to do because they're not eating.' Which of the following responses should the nurse make?
- A. Tell me more about what happens at mealtime.
- B. They may need a feeding tube.
- C. Have you tried offering different foods?
- D. Let's discuss ways to encourage their appetite.
Correct Answer: A
Rationale: Exploring mealtime details provides insight into the client’s eating issues.
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A nurse in a long-term care facility is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?
- A. Apply suction while inserting the catheter.
- B. Apply intermittent suction for up to 30 seconds.
- C. Preoxygenate the client prior to suctioning.
- D. Instruct the client to swallow during catheter insertion.
Correct Answer: C
Rationale: Preoxygenation prevents hypoxia during suctioning, enhancing safety.
A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Explain to the client that they cannot leave until the surgeon discharges them.
- C. Have the client sign an against medical advice form.
- D. Tell the client that the surgeon will prescribe restraints if they try to leave.
Correct Answer: C
Rationale: Signing an AMA form documents the client's informed decision to leave against advice.
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?
- A. Check the client's medical records to see which medications were recently administered.
- B. Review the client's most recent SaO2 level in the medical record.
- C. Notify the charge nurse of the client's condition.
- D. Recheck the client's SaO2 level after having the client cough and clear their throat.
Correct Answer: D
Rationale: Rechecking after coughing assesses if the low SaO2 is due to mucus, addressing it immediately.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma is draining a small amount of liquid stool.
- B. The stoma protrudes slightly from the abdomen.
- C. The stoma appears dark in color.
- D. The stoma bleeds lightly when touched.
Correct Answer: C
Rationale: A dark stoma suggests ischemia or necrosis, requiring urgent reporting.
A nurse is assisting in the care of a client who has pneumonia in the medical unit. Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)
- A. Take antibiotics for 10 days.
- B. Ensure the oxygen delivery system is at least 8 feet from any heat source.
- C. Decrease the steroid dose each day.
- D. Take antibiotic medication with or without food.
- E. Adjust the oxygen flow rate as needed to ease breathing.
- F. Take steroid medication in the morning.
Correct Answer: A,B,D,F
Rationale: A: Ensures full treatment course. B: Reduces fire hazard. D: Flexibility aids compliance. F: Morning dosing minimizes sleep disruption.