Nokea
A nurse is assisting with the care of a male client in the unit. Complete the following sentence by using the list of options. The client is at risk for developing ___ due to ___.
- A. Aspiration pneumonia
- B. Coughing when eating
- C. sweating
- D. increased heart beat
Correct Answer: A,B
Rationale: A: Coughing during eating increases aspiration risk. B: Indicates potential airway entry.
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A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
- A. Use a catheter securing device to hold the catheter in place.
- B. Obtain urine from the drainage bag if a urinary specimen is required.
- C. Change the catheter bag every 3 days and as needed.
- D. Position the drainage bag higher than the client's bladder.
Correct Answer: A
Rationale: Securing the catheter prevents movement and reduces infection risk.
A nurse is assisting in the care of a 72-year-old female client who recently had a stroke and is being monitored for complications. Complete the following sentence by using the lists of options. The client is at risk for developing ___ due to ___.
- A. Deep vein thrombosis (DVT)
- B. Prolonged immobility
- C. Urinary Catheter
- D. constipation
Correct Answer: A,B
Rationale: A: DVT is a risk post-stroke. B: Immobility increases clotting risk.
A nurse is caring for a client who is dying. One of the client's family members tells the nurse, 'I need to help. What can I do?' Which of the following actions should the nurse take?
- A. Suggest that the family member contact a grief counselor.
- B. Describe a personal experience with the death of a family member.
- C. Include the family member in providing care for the client.
- D. Ask if they have had prior experience with the death of a family member.
Correct Answer: C
Rationale: Involving the family member in care provides purpose and comfort.
A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?
- A. Unequal height of the shoulders.
- B. Increased concave curve of the thoracic spine.
- C. Expansion of the upper intercostal spaces.
- D. Increased convex curve of the cervical spine.
Correct Answer: A
Rationale: Unequal shoulder height is a classic sign of scoliosis due to lateral spinal curvature.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Orthostatic hypotension.
- B. BMI of 24.
- C. Type 1 diabetes mellitus.
- D. Family history of osteoporosis.
Correct Answer: C
Rationale: Type 1 diabetes increases cardiovascular risk due to vascular damage.