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A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?
- A. Instruct the client to tilt their head back to facilitate swallowing
- B. Encourage the client to use a straw.
- C. Provide oral care before meals.
- D. Schedule physical therapy directly before meals.
Correct Answer: C
Rationale: Oral care before meals removes debris and reduces aspiration risk in dysphagia. Tilting back worsens swallowing, straws may not be safe, and therapy timing isn't relevant.
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A nurse is caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take?
- A. Use a hair dryer to blow hot air into the cast to relieve itching.
- B. Perform neurovascular checks of the affected extremity every 2 hr.
- C. Position the fractured arm below the level of the client's heart.
- D. Immobilize the client's fingers using a hand splint.
Correct Answer: B
Rationale: Neurovascular checks every 2 hours assess circulation and nerve function, critical after cast application. Hot air can burn, elevation reduces swelling, and finger immobilization isn't standard unless specified.
A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?
- A. Absence of Chvostek's sign
- B. Presence of Kussmaul respirations
- C. Presence of diaphoresis
- D. Absence of urinary ketones
Correct Answer: B
Rationale: Kussmaul respirations indicate hyperglycemia-induced metabolic acidosis as the body compensates for high glucose. Chvostek's is unrelated, diaphoresis suggests hypoglycemia, and ketones may be present but aren't definitive here.
A nurse is collecting data from a client who had a long arm cast applied 2 hr. ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately?
- A. The client's fingers are cool to the touch.
- B. The client reports severe itching under the cast.
- C. The client's capillary refill is 3 seconds.
- D. The client reports increased pain at the area of the fracture.
Correct Answer: A
Rationale: Cool fingers suggest impaired circulation, a potential emergency post-cast application requiring immediate reporting. Itching and pain are common, and 3-second refill is borderline normal.
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Prescription: Administer an iron supplement.
- A. Administer an iron supplement
- B. Collaborate with a nutritional consultant.
- C. Place the client on a low sodium diet.
- D. Restrict fluid Intake.
Correct Answer:
Rationale: Low Hct, Hgb, and ferritin indicate iron deficiency anemia, making iron supplementation anticipated.
A nurse is reinforcing teaching with a client who wants to lose 0.9 kg (2 lb) of body fat per week. The nurse knows that 0.45 kg (1 lb) of body fat is equal to 3500 calories. The nurse should instruct the client to reduce his daily caloric intake by how many calories?
Correct Answer: 1000
Rationale: Calculation: 2 lb × 3,500 cal/lb = 7,000 cal/week; 7,000 ÷ 7 = 1,000 cal/day reduction achieves the weight loss goal.