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A nurse is caring for an 82-year-old client in the ER who has an oral body temperature of 38.3°C (101°F), a pulse rate of 114/min, & a respiratory rate of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all.
- A. Obtain culture specimens before initiating antimicrobials
- B. Restrict the client's oral fluid intake
- C. Encourage the client to limit activity & rest
- D. Allow the client to shiver to dispel excess heat
- E. Assist the client with oral hygiene frequently
Correct Answer: A, C, E
Rationale: Correct Answer: A, C, E
Rationale:
A: Obtaining culture specimens before initiating antimicrobials is crucial to identify the specific pathogen causing the infection and guide appropriate treatment.
C: Encouraging the client to limit activity & rest helps conserve energy and promote recovery in the presence of infection.
E: Assisting the client with oral hygiene frequently helps prevent further infection and maintain oral health, which is important in the elderly population.
Incorrect Choices:
B: Restricting the client's oral fluid intake is not appropriate as hydration is essential, especially in the presence of fever and infection.
D: Allowing the client to shiver to dispel excess heat is not recommended as it can lead to increased metabolic demand and discomfort for the client.
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A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? Select all.
- A. Social worker
- B. CNA
- C. Occupational therapist
- D. Speech-language pathologist
Correct Answer: C, D
Rationale: The correct answer is C and D. The occupational therapist (C) can help with improving the client's ability to eat independently by providing adaptive equipment and strategies. A speech-language pathologist (D) is crucial for assessing and treating dysphagia to prevent aspiration and improve swallowing function. The social worker (A) may address psychosocial needs but does not directly address dysphagia. The CNA (B) primarily assists with daily living activities.
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. Which of the following should the nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The presentation of linear clusters of fluid-containing vesicles with crusting is characteristic of herpes zoster, also known as shingles. This viral infection is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution of the vesicles along a dermatome is a key feature of herpes zoster. The other choices are incorrect because: A: Allergic reactions typically present with hives or itching, not vesicles with crusting. B: Ringworm presents as circular, red, scaly patches, not linear clusters of vesicles. C: Systemic lupus erythematosus is an autoimmune disease that manifests with a butterfly rash on the face, joint pain, and other systemic symptoms, not vesicles. Therefore, the nurse should suspect herpes zoster based on the presentation described.
A nurse is teaching a client about taking multiple oral meds at home to include time-release capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can open the capsule w/the beads in it & sprinkle them on my oatmeal.
- B. If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding.
- C. The pills w/the coating on them can be crushed.
- D. I will eat 2 crackers w/the pain pills.
Correct Answer: D
Rationale: The correct answer is D: "I will eat 2 crackers with the pain pills." This statement indicates an understanding of the teaching because taking narcotics with food, such as crackers, can help reduce stomach upset and nausea commonly associated with these medications. This demonstrates the client's awareness of the importance of food intake when taking certain medications.
Choice A is incorrect because opening a time-release capsule and sprinkling the beads on food can alter the medication's intended release mechanism. Choice B is incorrect as mixing liquid meds with pudding may not ensure proper dosage or absorption. Choice C is incorrect as crushing enteric-coated pills can interfere with their delayed-release properties.
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.
- A. Keep the head of the bed elevated 30 degrees
- B. Massage the client's bony prominences often
- C. Apply cornstarch liberally to the skin after bathing
- D. Have the client sit on a gel cushion when in a chair
- E. Reposition the client at least Q 3 hr while in bed
Correct Answer: A, D
Rationale: The correct interventions (A and D) are crucial for preventing pressure ulcers in older adults. Elevating the head of the bed at 30 degrees helps reduce pressure on the sacrum and heels, key areas prone to pressure ulcers. Sitting on a gel cushion distributes pressure evenly, reducing the risk of skin breakdown.
Incorrect Choices:
B: Massaging bony prominences can increase friction and shear forces, leading to skin breakdown.
C: Cornstarch can create a moist environment, increasing the risk of maceration and skin breakdown.
E: Repositioning every 3 hours is insufficient for preventing pressure ulcers, as more frequent repositioning is needed to reduce prolonged pressure on the skin.
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
- A. Macaroni & cheese
- B. Fresh fruit & whole wheat toast
- C. Rice pudding & ripe bananas
- D. Roast chicken & white rice
Correct Answer: B
Rationale: The correct answer is B: Fresh fruit & whole wheat toast. Fresh fruits are high in fiber, which aids in digestion and helps prevent constipation. Whole wheat toast also contains fiber, promoting regular bowel movements. Macaroni & cheese (A) and rice pudding & ripe bananas (C) are low in fiber and may worsen constipation. Roast chicken & white rice (D) lack sufficient fiber to alleviate constipation.