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A nurse is conducting a dysphagia screening on a client who was recently extubated. Which assessment finding requires intervention?
- A. Slight cough after sipping water.
- B. Hoarseness of voice during speech.
- C. Reports of mild throat discomfort when swallowing.
- D. Presence of a wet, gurgling cough after drinking water.
Correct Answer: D
Rationale: A wet, gurgling cough after drinking water (D) indicates possible aspiration, requiring immediate intervention to prevent complications like pneumonia. Slight cough (A), hoarseness (B), and mild discomfort (C) are less urgent.
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A nurse is caring for a client with ulcerative colitis who has experienced severe diarrhea for the past 24 hours. When assessing the client, the nurse should watch for signs of which of the following?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Malnutrition
- D. Malabsorption
Correct Answer: C
Rationale: Severe diarrhea in ulcerative colitis leads to nutrient loss, increasing the risk of malnutrition (C). Acid-base imbalances (A, B) and malabsorption (D) are possible but less immediate concerns.
The nurse is teaching a client about their newly established colostomy. Which of the following statements by the client would require follow-up?
- A. I will call my primary healthcare provider (PHCP) immediately if my stoma becomes bluish.
- B. I should slowly introduce high-fiber foods in my diet.
- C. I must always wear a pouch over my stoma.
- D. I should clean the skin around my stoma with rubbing alcohol.
Correct Answer: D
Rationale: Using rubbing alcohol (D) can irritate the skin around the stoma. Options A, B, and C are appropriate for colostomy care.
Which of the following clients does the nurse suspect would benefit most from placement of a nasogastric tube?
- A. A 9-year-old client with a femur fracture.
- B. An 82-year-old client with congestive heart failure.
- C. A 65-year-old client on dialysis.
- D. A 52-year-old client with leukemia who is receiving chemotherapy.
Correct Answer: D
Rationale: A client receiving chemotherapy (D) may experience severe nausea and vomiting, necessitating an NG tube for decompression or feeding. The other conditions are less likely to require NG tube placement.
The nurse is positioning a client following a liver biopsy. Which position is best suited for this client?
- A. On the left side with a pillow under the ribs.
- B. Supine with a pillow under the client's knees.
- C. Face down with a pillow under the hips.
- D. On the right side with a pillow under the biopsy site.
Correct Answer: D
Rationale: The right-side position with a pillow under the biopsy site (D) applies pressure to prevent bleeding post-liver biopsy.
The nurse is teaching a client about peptic ulcer disease. Which of the following statements should the nurse include?
- A. You should take aspirin if you have mild aches or pains.
- B. You will need to consume liquids one hour after each meal.
- C. It will be important to reduce the stress in your life.
- D. Take your prescribed omeprazole with food.
Correct Answer: C
Rationale: Stress reduction (C) helps manage peptic ulcer disease by reducing acid secretion. Aspirin (A) worsens ulcers, liquids with meals (B) are not restricted, and omeprazole (D) is taken before meals.