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A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?
- A. Pulmonary embolism
- B. Diarrhea
- C. Pneumonia
- D. Pressure injury
Correct Answer: C
Rationale: Pneumonia, especially aspiration pneumonia, is a major risk in dysphagia due to potential inhalation of food or liquids.
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A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Peripheral edema
- C. Oliguria
- D. Bradycardia
Correct Answer: B
Rationale: Peripheral edema occurs in hypervolemia as excess fluid accumulates in tissues.
A nurse is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following should be included as a responsibility of the nurse in this process?
- A. Discuss the risks of the procedure with the client.
- B. Confirm that the client is competent to sign for the procedure.
- C. Explain alternatives to the procedure to the client.
- D. Inform the client about what will occur during the procedure.
Correct Answer: B
Rationale: The nurse ensures the client's competence to consent, while the physician explains risks and procedures.
A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Identify the clients at greatest risk for development of pressure ulcers.
- B. Use a barrier cream when performing perineal care.
- C. Turn and position each client every 2 hr.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: A
Rationale: Identifying at-risk clients prioritizes preventive efforts for pressure ulcer management.
A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications?
- A. Postoperative cognitive dysfunction
- B. Dementia
- C. Alzheimer's disease
- D. Postoperative delirium
Correct Answer: D
Rationale: Postoperative delirium causes acute, temporary confusion post-surgery, common in older adults.
A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
- A. Partial-thickness skin loss with red tissue in the wound bed.
- B. Intact skin with localized erythema.
- C. Full-thickness skin loss with visible adipose tissue.
- D. Full-thickness skin loss with visible bone.
Correct Answer: A
Rationale: Stage 2 pressure injuries show partial-thickness loss with a red wound bed, indicating damage to epidermis and possibly dermis.