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A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?
- A. Physical therapist
- B. Speech-language pathologist
- C. Occupational therapist
- D. Social worker
Correct Answer: C
Rationale: The correct answer is C: Occupational therapist. Occupational therapists specialize in helping individuals regain skills needed for daily activities, such as using eating utensils. They focus on enhancing fine motor skills and cognitive abilities necessary for independent living. Referring the client to an occupational therapist will ensure a comprehensive approach to relearning utensil use. Physical therapists (A) focus on mobility and strength, not fine motor skills. Speech-language pathologists (B) address communication and swallowing issues, not utensil use. Social workers (D) assist with psychosocial support, not utensil retraining.
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A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
- A. Change the PN infusion bag every 48 hr.
- B. Obtain a random blood glucose daily.
- C. Prepare the client for a central venous line.
- D. Administer the PN and fat emulsion separately.
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for a central venous line. Parenteral nutrition (PN) with high dextrose concentrations can cause phlebitis and tissue damage if administered through a peripheral IV line. Therefore, a central venous line is appropriate for administering PN to prevent complications. Changing the PN bag every 48 hours (A) is important for infection control but not directly related to the administration method. Obtaining a random blood glucose daily (B) is important for monitoring glucose levels but does not address the administration method. Administering the PN and fat emulsion separately (D) is not necessary as they can be mixed in the same solution.
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
- A. The client drinks their thickened juice with a straw.
- B. The client adjusts the head of their bed to 90°.
- C. The client tucks their chin when they swallow.
- D. The client takes frequent breaks while eating.
Correct Answer: A
Rationale: Correct Answer: A. The client drinking thickened juice with a straw indicates a potential aspiration risk. Straws can bypass the oral phase of swallowing, increasing the likelihood of aspiration. Thickened liquids are meant to slow down the flow of fluids to prevent choking or aspiration. Therefore, the nurse should intervene to prevent potential harm to the client.
Incorrect Choices:
B: Adjusting the head of the bed to 90° is the correct positioning to prevent aspiration during swallowing.
C: Tucking the chin when swallowing helps to protect the airway and prevent aspiration.
D: Taking frequent breaks while eating is a good strategy for clients with dysphagia to prevent fatigue and reduce the risk of aspiration.
A nurse is administering multiple types of ophthalmic drugs to a client. Which of the following actions should the nurse take?
- A. Hold the dropper 3 cm (1.2 in) away from the client's eye.
- B. Ask the client to close their eyes tightly after instilling each medication.
- C. Massage the client's eyelids for 2-3 seconds after instillation.
- D. Wait 5 min between the administration of each medication.
Correct Answer: D
Rationale: The correct answer is D: Wait 5 min between the administration of each medication. This is important to prevent dilution or interaction between the different ophthalmic medications. Administering multiple medications too close together can reduce the effectiveness of each medication. Holding the dropper at a specific distance (A) is not as critical as allowing time between administrations. Asking the client to close their eyes tightly (B) or massaging the eyelids (C) after instillation can disrupt the medication and should be avoided. Waiting for 5 minutes allows each medication to be properly absorbed before the next one is administered, ensuring optimal therapeutic effects.
A nurse is preparing to administer prescribed medications to a client. According to the rights of medication administration, when should the nurse compare the medication administration record against the medication container? (Select all that apply.)
- A. While removing medication from the container
- B. Before selecting the medication container
- C. When documenting the medication administration
- D. When providing client education about the medication
- E. At the client's bedside before administering the medication
Correct Answer: A, B,E
Rationale: The correct answers are A, B, and E. Comparing the medication administration record against the container before removing the medication ensures accuracy. Before selecting the container, the nurse confirms the correct medication. At the client's bedside, the nurse verifies the medication before administration to prevent errors. Choice C is incorrect because documentation should occur after administration. Choice D is incorrect as medication reconciliation is not part of client education.
A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
- A. Obtain a raised toilet seat for the bathroom.
- B. Secure loose wires under carpeting.
- C. Use extension cords to prevent overloading circuits.
- D. Cover slippery stairs with an area rug.
Correct Answer: A
Rationale: The correct answer is A: Obtain a raised toilet seat for the bathroom. This is important for older adults to prevent falls and make it easier for them to use the toilet safely. Raised toilet seats reduce the risk of strain or injury while sitting down or getting up.
Incorrect choices:
B: Securing loose wires under carpeting can still pose a tripping hazard.
C: Using extension cords can lead to electrical hazards and fires.
D: Covering slippery stairs with an area rug can increase the risk of falls due to slipping.