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A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?
- A. Rapid chewing
- B. Increased hunger
- C. Garbled voice
- D. Sneezing
Correct Answer: C
Rationale: A garbled voice indicates swallowing difficulty, a sign of dysphagia.
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A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?
- A. Determine if the client has a support system.
- B. Schedule a mental health consult for the client.
- C. Provide the client with information about coping strategies.
- D. Encourage the client to attend a support group.
Correct Answer: A
Rationale: Assessing the support system first identifies resources to address ineffective coping.
A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps, placing them in the order of performance. Use all the steps.)
- A. Pinch and withdraw the tube.
- B. Disconnect the tube from the suction device.
- C. Instill 50 mL of air into the tube.
- D. Ask the client to take a deep breath.
- E. Apply clean gloves.
Correct Answer: E,B,C,D,A
Rationale: E: Gloves first. B: Disconnect suction. C: Instill air clears tube. D: Deep breath aids removal. A: Pinch and withdraw.
A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?
- A. Cotton-tipped applicator
- B. Tongue depressor
- C. Adhesive tape
- D. Syringe
Correct Answer: D
Rationale: A syringe is used for irrigation to clean a stage 4 pressure injury with deep tissue involvement.
A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?
- A. Drink citrus juice with meals.
- B. Train the bladder by voiding every 5 hr.
- C. Perform pelvic-muscle exercises.
- D. Apply adult diapers at bedtime.
Correct Answer: C
Rationale: Pelvic-muscle exercises (Kegels) strengthen muscles to reduce incontinence.
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
- A. Ask the client to state their room number.
- B. Have the client state their phone number.
- C. Review the client's photograph in the medical record.
- D. Request an assistive personnel to identify the client.
Correct Answer: C
Rationale: A photograph in the record is a reliable identifier for a client with dementia.