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A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?
- A. Obtain the client's peak expiratory flow volume.
- B. Encourage the client to cough.
- C. Place the client in a semi-Fowler's position.
- D. Encourage the client to use a straw to sip cool liquids.
Correct Answer: C
Rationale: Placing the client in a semi-Fowler's position promotes airway clearance and comfort post-tonsillectomy, especially with an SpO2 of 93%.
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A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?
- A. The client has inspiratory stridor
- B. The client reports a sore throat.
- C. The client's sputum has streaks of blood.
- D. The client's temperature is 38.6°C / 101.4°F
Correct Answer: A
Rationale: Inspiratory stridor indicates possible airway obstruction or swelling post-bronchoscopy, a serious complication requiring immediate reporting.
A nurse is reinforcing dietary teaching with a client who is postoperative and adheres to a vegetarian diet. Which of the following foods should the nurse recommend to the client as containing the highest amount of protein?
- A. Tomato soup
- B. Bananas
- C. Avocado
- D. Black beans
Correct Answer: D
Rationale: Black beans are a rich source of plant-based protein, making them the best recommendation for a vegetarian client needing protein post-surgery.
A nurse is contributing to the plan of care for a client who has had severe diarrhea for the past 3 days and is now beginning solid foods. Which of the following foods should the nurse include in the plan of care?
- A. Applesauce
- B. Orange slices
- C. Bran cereal
- D. Cottage cheese
Correct Answer: A
Rationale: Applesauce is gentle on the digestive system and helps firm stools, suitable for reintroducing solids after diarrhea.
A nurse is reinforcing teaching with a client who is to take a fecal occult blood test at home. Which of the following instructions should the nurse include in the teaching?
- A. Apply five drops of developer to each smear.
- B. Use the same part of stool for each sample.
- C. Ensure the sample contains no urine.
- D. Wait 10 min before applying the developing solution.
Correct Answer: C
Rationale: Ensuring the sample is free of urine prevents contamination, which could lead to inaccurate fecal occult blood test results.
A nurse is reinforcing teaching with a client who has gastroesophageal reflux (GERD). Which of the following statements by the client indicates an understanding of the teaching?
- A. I will lie down for 30 minutes after each meal.
- B. I will increase vitamin C intake by drinking orange juice.
- C. I will sleep flat on my back at night.
- D. I will eat six small meals each day.
Correct Answer: D
Rationale: Eating six small meals reduces stomach pressure and reflux, indicating understanding of GERD management.