Nokea
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.
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A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?
- A. I will turn my mother on her left side during the feeding.
- B. I will position the head of the bed 45 degrees during the feeding.
- C. I will allow the position my mother finds most comfortable during the feeding.
- D. I will elevate the head of the bed 10 degrees during the feeding.
Correct Answer: B
Rationale: Elevating the bed 45 degrees prevents aspiration and aids digestion during feedings.
A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)
- A. Bradycardia
- B. An increase in platelets
- C. An increase in RBCs
- D. An increase in neutrophils
- E. Localized edema
Correct Answer: D,E
Rationale: D: An increase in neutrophils is a common response to bacterial infection. E: Localized edema indicates inflammation from infection. A, B, and C are not typical infection signs.
A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?
- A. Tremors
- B. Bradycardia
- C. Decreased appetite
- D. Flushed skin
Correct Answer: A
Rationale: Tremors are a common hypoglycemia symptom due to the body's stress response.
A nurse is assisting with teaching a class about minerals. Which of the following minerals is needed for transport of oxygen?
- A. Phosphorus
- B. Iron
- C. Magnesium
- D. Potassium
Correct Answer: B
Rationale: Iron in hemoglobin binds oxygen for transport in the blood.
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
- A. To remove gastric acid that might cause dyspepsia
- B. To identify delayed gastric emptying
- C. To confirm the placement of the NG tube
- D. To determine the client's electrolyte balance
Correct Answer: B
Rationale: Measuring residual identifies delayed gastric emptying, reducing aspiration risk.