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A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
- A. Promote oral hygiene.
- B. Ensure adequate nutrition.
- C. Prevent aspiration.
- D. Relieve the client’s pain.
Correct Answer: C
Rationale: The correct answer is C: Prevent aspiration. This is the priority because with intermaxillary fixation, the client's ability to swallow and protect their airway is compromised. Aspiration can lead to serious complications such as pneumonia. Promoting oral hygiene (A) can be important but not the priority. Ensuring adequate nutrition (B) is important but can be addressed once the risk of aspiration has been minimized. Relieving pain (D) is also important but not the priority over preventing aspiration in this case.
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A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?
- A. Use wool blankets on your bed.
- B. Do not adjust the oxygen flow rate.
- C. Store unused oxygen tanks horizontally.
- D. Check your oxygen equipment once each week.
Correct Answer: B
Rationale: The correct answer is B: Do not adjust the oxygen flow rate. It is essential not to adjust the oxygen flow rate as it is prescribed by a healthcare provider based on the client's condition. Incorrectly adjusting the flow rate can lead to inadequate oxygen delivery or oxygen toxicity. Choice A is incorrect as wool blankets can generate static electricity, which can be dangerous around oxygen. Choice C is incorrect because oxygen tanks should be stored vertically to prevent accidents. Choice D is incorrect as oxygen equipment should be checked daily for safety and functionality.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Generalized urticaria.
- B. Distended jugular veins.
- C. Blood pressure 184/92 mm Hg.
- D. Bilateral flank pain.
Correct Answer: A
Rationale: The correct answer is A: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. The release of histamine during the reaction causes itching and skin rash. Distended jugular veins (B) are more indicative of fluid overload or heart failure. Blood pressure of 184/92 mm Hg (C) is elevated but not specific to an allergic reaction. Bilateral flank pain (D) may suggest kidney issues or musculoskeletal problems, not necessarily related to an allergic reaction.
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Handrails are present in the bathroom.
- B. Electrical cords are placed along the walls.
- C. Uses a microwave for cooking.
- D. Scatter rugs are present in the kitchen.
Correct Answer: D
Rationale: The correct answer is D: Scatter rugs are present in the kitchen. Scatter rugs can pose a safety risk for an older adult with decreased vision due to glaucoma as they increase the risk of tripping and falling. The uneven surface and lack of secure placement make scatter rugs hazardous. Handrails in the bathroom (A) enhance safety, electrical cords along the walls (B) may be a tripping hazard but can be easily addressed, and using a microwave for cooking (C) is a safe and convenient option for someone with decreased vision.
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?
- A. Take naproxen for generalized discomfort
- B. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week
- C. Take diuretics early in the morning and before bedtime
- D. Exercise at least three times per week
Correct Answer: B
Rationale: The correct answer is B: Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. This is crucial in heart failure management as sudden weight gain can indicate fluid retention, worsening heart failure, and the need for medication adjustment. Option A is incorrect as naproxen can worsen heart failure symptoms. Option C is incorrect as diuretics should be taken in the morning to prevent nighttime urination. Option D is incorrect as the frequency and intensity of exercise should be tailored based on the individual's condition.
A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?
- A. Your largest meal of the day should be in the evening.
- B. Eating yogurt can help decrease the amount of gas that I have.
- C. Carbonated beverages can help control odor.
- D. I should eliminate pasta from my diet so that I don’t have many loose stools.
Correct Answer: B
Rationale: The correct answer is B because eating yogurt can help decrease gas due to its probiotic properties which aid in digestion. This statement shows the client understands dietary adjustments post-colostomy surgery. Choice A is incorrect as meal distribution does not affect colostomy care. Choice C is incorrect as carbonated beverages can worsen odor. Choice D is incorrect as pasta is not necessarily a problematic food post-colostomy.