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A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
- A. Take pancrelipase.
- B. Complete oral hygiene.
- C. Eat a meal.
- D. Use an albuterol inhaler.
Correct Answer: D
Rationale: The correct answer is D: Use an albuterol inhaler. Prior to postural drainage, the client with cystic fibrosis should use an albuterol inhaler to help open up the airways and facilitate effective mucus clearance during the procedure. Albuterol is a bronchodilator that helps to relax the muscles in the airways, making it easier to breathe and improving the effectiveness of postural drainage. Pancrelipase (choice A) is taken with meals to aid in digestion, so it is not necessary before postural drainage. Completing oral hygiene (choice B) is important but not directly related to postural drainage. Eating a meal (choice C) may lead to discomfort during the procedure. The priority is to ensure clear airways with the use of the albuterol inhaler.
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A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords.
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction is important because rugs with rubber backs are less likely to slip, reducing the risk of falls for the older adult post knee replacement surgery. Choice A is incorrect as wearing shoes at home can increase the risk of falls due to slippery surfaces. Choice B is incorrect as placing a throw rug over electrical cords can create a tripping hazard. Choice C is incorrect as marking the edges of the doorway with tape does not address the risk of tripping over rugs.
A nurse is caring for a recently admitted 18-year-old client:
Nurses' Notes
1000:
Client admitted to behavioral health unit for prolonged weight loss and refusal to eat. Client collapsed at school. The client's parents were called. They contacted the primary care provider, who arranged for a direct admission.
Weight 37.2 kg (82 lb)
Height 157.5 cm (62 inches)
BMI 15
1200:
Client observed during noon meal. Client pushed food around the plate. Intake 10% of meal. Offered nutritional supplement. Client declined. Reports feeling anxious due to admission and mealtime. Client states, "I cannot eat this with you watching me."
1500:
Snack provided. Client observed throwing snack into the trash can. When realized they had been observed, they admitted to their action and asked for a second snack. Client ate 10% of their snack.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Provide the client, with foods that have a variety of textures, Accept the client’s belief about "forbidden" foods, Focus on the client’s underlying feelings of lack of control, Encourage the client to limit fasting, Provide a structured meal environment.
- B. Bulimia Nervosa, Binge eating disorder, Anorexia nervosa, Avoidant/restrictive food intake disorder.
- C. Cardiac function with ECG, Weight on a daily basis, Calcium level, Vital signs every 8 hr, Behavior 15min after meals.
Correct Answer: A[2,4],B[2],C[0,4]
Rationale: Action to Take: Provide the client with foods that have a variety of textures, Encourage the client to limit fasting; Potential Condition: Anorexia nervosa; Parameter to Monitor: Weight on a daily basis, Behavior 15 minutes after meals.
Rationale: In anorexia nervosa, the client typically has a fear of gaining weight, leading to restrictive eating habits. Providing foods with different textures can help normalize eating habits and improve nutrition. Encouraging the client to limit fasting can help address the underlying issue of restricted food intake. Weight monitoring is crucial in assessing nutritional status, while monitoring behavior post-meals can provide insights into the client's relationship with food. Bulimia nervosa and binge eating disorder are not the most likely conditions based on the client's symptoms. Monitoring cardiac function with ECG and calcium level are not the primary parameters for assessing progress in anorexia nervosa.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the epiglottis becomes inflamed and can lead to airway obstruction. Intubation may be necessary to secure the airway and ensure the child can breathe. It is a priority action to maintain the child's oxygenation and ventilation. Obtaining a throat culture (B) can be important for diagnosis but is not the immediate priority. Suctioning the child's oropharynx (C) can trigger a spasm and worsen the obstruction. Cool mist tent (D) is not indicated in the management of epiglottitis.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords.
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction is important to prevent slips and falls, as rubber-backed rugs provide better traction on smooth surfaces, reducing the risk of accidents. Placing throw rugs over electrical cords (B) can cause tripping hazards. Marking the edges of the doorway with tape (C) may not be effective and can be unsightly. Encouraging the client to avoid wearing shoes at home (A) may not directly impact safety. Overall, ensuring area rugs have rubber backs (D) is the most practical and effective approach to enhancing home safety for a postoperative older adult.
Nurses' Notes
4 weeks ago:
21-year-old client reports increased stress and worry for the last 3 months. Client is worried about academic performance due to Inability to focus on studies. School performance is suffering. Denies illicit drug use and drinks in moderation socially on the weekends.
Discussed lifestyle modifications to reduce stress. Instructed client to return in 1 month to reevaluate symptoms.
Today:
Client reports a slight improvement in stress but is now having loss of appetite and difficulty sleeping.
Instructed client to begin trazodone per provider's prescription.
A nurse is caring for a client in the outpatient health clinic. For each potential nursing Intervention, click to specify if the intervention is indicated or not indicated.
- A. Encourage naps during the day when client is tired.
- B. Encourage a regular sleep-wake schedule.
- C. Encourage high-calorie finger foods.
- D. Advise client to notify provider if pregnant.
- E. Instruct client to avoid foods that have been fermented or aged.
- F. Advise client to rise slowly from sitting position.
- G. Encourage client to sleep until later in the morning.
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Encouraging naps during the day when the client is tired is indicated for managing fatigue.
- Encouraging a regular sleep-wake schedule helps promote better sleep hygiene.
- Advising the client to notify the provider if pregnant is crucial for appropriate prenatal care.
- Other options are not indicated: high-calorie finger foods may not be suitable for all clients, avoiding fermented or aged foods is specific dietary advice, rising slowly is for orthostatic hypotension, and sleeping until later in the morning may disrupt the sleep-wake cycle.