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A nurse is providing discharge teaching to a client who has had a stroke. Which of the following instructions should the nurse include?
- A. Avoid taking anticoagulant medication.
- B. Limit fluid intake to 1,000 mL per day.
- C. Avoid isometric exercises during recovery.
- D. Perform range-of-motion exercises daily.
Correct Answer: D
Rationale: The correct answer is D: Perform range-of-motion exercises daily. After a stroke, performing range-of-motion exercises can help prevent complications such as joint stiffness and contractures. Options A, B, and C are incorrect. Anticoagulant medications are often prescribed to prevent blood clots after a stroke, fluid intake should be adequate unless indicated otherwise, and isometric exercises can be beneficial during recovery.
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A nurse is caring for a client who is experiencing dysphagia. Which of the following interventions should the nurse implement?
- A. Administer thickened liquids.
- B. Provide small bites of food.
- C. Encourage the client to eat quickly to avoid fatigue.
- D. Have the client lie supine after meals.
Correct Answer: A
Rationale: The correct intervention for a client with dysphagia is to administer thickened liquids. Thickened liquids help prevent aspiration, which is a common risk for clients with swallowing difficulties. Providing small bites of food (choice B) can help, but the priority is to modify the liquid consistency. Encouraging the client to eat quickly (choice C) is not recommended as it may increase the risk of aspiration and fatigue. Having the client lie supine after meals (choice D) can actually increase the risk of aspiration, especially in clients with dysphagia.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?
- A. Oxygen saturation of 92%
- B. Use of pursed-lip breathing
- C. Increased anterior-posterior chest diameter
- D. Productive cough with green sputum
Correct Answer: D
Rationale: The correct answer is D. A productive cough with green sputum can indicate a bacterial infection, which is a concern for clients with COPD. Reporting this finding to the provider is important for further evaluation and management. Choices A, B, and C are not as concerning in the context of COPD management. An oxygen saturation of 92% is within an acceptable range for COPD patients, pursed-lip breathing is a helpful technique for managing breathing difficulties in COPD, and an increased anterior-posterior chest diameter is a common finding in clients with COPD due to chronic air trapping.
A nurse is planning care for a client who has a new prescription for a peripheral intravenous (IV) catheter. Which of the following actions should the nurse take to prevent infection?
- A. Shave the hair at the insertion site.
- B. Cleanse the site with povidone-iodine.
- C. Wear sterile gloves when changing the dressing.
- D. Change the IV site every 48 to 72 hours.
Correct Answer: D
Rationale: The correct action to prevent infection when caring for a client with a new peripheral IV catheter is to change the IV site every 48 to 72 hours. Shaving the hair at the insertion site can actually increase the risk of infection by causing microabrasions in the skin. While cleansing the site with povidone-iodine is important before insertion, it is not necessary to continue doing so once the IV is in place. Wearing sterile gloves when changing the dressing is crucial for maintaining aseptic technique but does not directly prevent infection related to the IV site itself.
A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include?
- A. Resume a regular diet immediately.
- B. Remove the adhesive bandage after 3 days.
- C. Begin moderate activity immediately.
- D. Take a tub bath instead of a shower.
Correct Answer: B
Rationale: The correct answer is B. The adhesive bandage should be removed 3 days after a laparoscopic cholecystectomy to allow the incision to heal properly. Choice A is incorrect as the client should start with a clear liquid diet and advance to a regular diet as tolerated. Choice C is incorrect because the client should gradually increase activity levels as tolerated. Choice D is incorrect as the client should avoid tub baths and opt for showers to prevent infection and promote healing.
A nurse is caring for a client who is receiving radiation therapy. Which of the following findings should the nurse expect?
- A. Weight gain
- B. Mouth sores
- C. Hyperpigmentation
- D. Increased saliva production
Correct Answer: B
Rationale: The correct answer is B: Mouth sores. Mouth sores are a common side effect of radiation therapy, especially when the treatment is focused on the head or neck area. Weight gain is not typically associated with radiation therapy; instead, clients may experience weight loss due to side effects like nausea and loss of appetite. Hyperpigmentation is not a common finding related to radiation therapy. Increased saliva production is not a typical side effect of radiation therapy; instead, clients may experience dry mouth.