Nokea
A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?
- A. Initiate fall precautions.
- B. Apply petroleum jelly to the client's nares.
- C. Implement contact precautions.
- D. Maintain the client in a supine position.
Correct Answer: A
Rationale: Hypoxia increases fall risk due to weakness or confusion, making fall precautions essential in aspiration pneumonia care.
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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 assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Clamp the tube for 30 min every 8 hr.
- B. Pin the tubing to the client's bed sheets.
- C. Monitor for at least 150 mL of drainage every hour.
- D. Replace the unit when the drainage chamber is full.
Correct Answer: D
Rationale: Replacing the unit when the drainage chamber is full ensures proper function and prevents complications, such as obstruction or infection, in a closed-chest tube system.
Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
A nurse is assisting with the care of the client Complete the following sentence by using the list of options. The nurse should first plan to.... followed by.....
- A. Determine if the nasogastric tube is in the correct position
- B. Provide oral care to the client
- C. Increase nasogastric tube suction
- D. Request a prescription for an antiemetic
- E. Document the client's pain level
- F. Monitor the client's electrolyte levels
Correct Answer: A,D
Rationale: The nurse should first ensure the nasogastric tube is correctly placed to address vomiting and obstruction, followed by requesting an antiemetic to manage nausea.
A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
The nurse is collecting data on the client. Which of the following findings require follow up?
- A. Findings of right lower extremity assessment
- B. Pain level
- C. Level of consciousness
- D. Oxygen saturation
- E. Right pedal pulses
- F. Temperature
- G. X-ray results
Correct Answer: A,B,E
Rationale: Right lower extremity findings (swelling, open wound), severe pain, and weak right pedal pulses indicate potential fracture or vascular compromise needing follow-up.
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
- A. Keep both arms below the level of the client's heart.
- B. Obtain blood pressure readings using the client's right arm.
- C. Use the client's left arm to obtain blood samples.
- D. Limit range-of-motion exercises with the affected arm
Correct Answer: C
Rationale: Using the left arm for blood samples avoids trauma to the right arm, reducing the risk of lymphedema after a right mastectomy.