Nokea
A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention?
- A. Give the client thin liquids.
- B. Instruct the client to tuck her chin when swallowing.
- C. Have the client use a straw.
- D. Encourage the client to lie down and rest after meals.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to tuck her chin when swallowing. This intervention helps prevent aspiration by closing off the airway during swallowing, reducing the risk of food or liquids entering the lungs. Tucking the chin also helps direct the food or liquid down the esophagus. Giving thin liquids (choice A) can increase the risk of aspiration. Using a straw (choice C) may also increase the risk by bypassing the natural protective mechanisms. Encouraging the client to lie down after meals (choice D) can lead to aspiration due to decreased muscle tone and gravity assisting in food or liquid entering the airway.
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A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by the body's inability to regulate its temperature due to prolonged exposure to high temperatures. This leads to excessive sweating and dehydration, resulting in a drop in blood pressure (hypotension). Bradycardia (B) is a slow heart rate, which is not typically seen in heat stroke. Clammy skin (C) is common in heat exhaustion, not heat stroke. Bradypnea (D) is slow breathing, which is not a common sign of heat stroke. Therefore, hypotension is the most appropriate choice as it aligns with the pathophysiology of heat stroke.
A nurse is reviewing the reported medications of a client who was recently admitted. The medications include cimetidine (Tagamet) and imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects?
- A. Decreased therapeutic effects of cimetidine
- B. Increased risk of imipramine hydrochloride toxicity
- C. Decreased risk of adverse effects of cimetidine
- D. Increased therapeutic effects of imipramine hydrochloride
Correct Answer: B
Rationale: The correct answer is B: Increased risk of imipramine hydrochloride toxicity. Cimetidine inhibits the metabolism of imipramine hydrochloride, leading to increased levels of imipramine in the body. This can result in a higher concentration of imipramine, potentially causing toxicity. This interaction is known as a pharmacokinetic drug-drug interaction.
Incorrect choices:
A: Decreased therapeutic effects of cimetidine - This is incorrect because cimetidine's therapeutic effects are not directly impacted by its interaction with imipramine.
C: Decreased risk of adverse effects of cimetidine - This is incorrect as there is no evidence to suggest that the interaction with imipramine decreases the risk of adverse effects of cimetidine.
D: Increased therapeutic effects of imipramine hydrochloride - This is incorrect as the increased risk of toxicity does not equate to increased therapeutic effects.
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all.
- A. The physical therapist didn't ambulate the client today
- B. The skin barrier's seal stays on in bed but loosens when the client stands.
- C. The client seemed to welcome having a 'day off' from physical therapy
- D. The wound care nurse will see the client later today
- E. The client ate all the food on her lunch tray
Correct Answer: A, B, D
Rationale: The correct choices to include in the change-of-shift report are A, B, and D. Choice A is important to communicate as it highlights that the physical therapist did not ambulate the client due to difficulties with the skin barrier and fistula drainage. Choice B is crucial as it explains the specific issue with the skin barrier, emphasizing that it stays intact when the client is supine but loosens when standing. Choice D is essential to include as it informs about the upcoming visit from the wound care nurse. Choices C and E, although relevant to the client's well-being, are not directly related to the current care plan and should not be included in the report.
A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam (Valium). Prior to administering the medication, which of the following actions is the highest priority?
- A. Teaching the client about the purpose of the medication
- B. Administering the medication to the client at the prescribed time
- C. Identifying the client's medication allergies
- D. Documenting the client's anxiety level
Correct Answer: C
Rationale: The highest priority action before administering any medication is to identify the client's medication allergies to prevent potential adverse reactions. Administering diazepam without knowing the client's allergies could lead to serious complications. Teaching the client about the medication's purpose is important but not as critical as ensuring the client does not have allergies. Administering the medication at the prescribed time is important but comes after ensuring safety. Documenting anxiety level is relevant but not as urgent as identifying allergies.
A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report?
- A. The client's input & output for the shift
- B. The client's BP from the previous day
- C. A bone scan that is scheduled for today
- D. The med routine from the med administration record
Correct Answer: C
Rationale: The correct answer is C: A bone scan that is scheduled for today. Including this information in the report is crucial as it alerts the oncoming nurse about the upcoming procedure, allowing them to plan and prepare accordingly. This is important for ensuring the client receives timely and appropriate care. The other choices are incorrect because: A (input & output) is important but may not be the priority for a change-of-shift report; B (BP from the previous day) is outdated information and may not be relevant for the current shift; D (med routine) should be documented in the client's chart and can be accessed by the oncoming nurse as needed.