Nokea
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?
- A. I understand that I can change my mind anytime
- B. I have a living will that outlines my wishes when I am unable to make a decision
- C. I need to inform my family about my wishes
- D. I don't need to worry about advance directives right now
Correct Answer: B
Rationale: Having a living will indicates the client understands that it outlines their wishes regarding medical treatment when they are unable to make decisions.
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A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Increased appetite
- B. Nausea
- C. Weight gain
- D. Regular bowel movements
Correct Answer: B
Rationale: Nausea is a sign of intolerance to enteral feedings, which may also include vomiting and dumping syndrome.
A nurse is planning to administer several medications to a client through an NG tube. Which actions should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Use 30-40 mL of sterile water for each medication
- C. Dissolve crushed tablet medications in sterile water
- D. Administer medications without dissolving
Correct Answer: C
Rationale: Crushed tablet medications should be dissolved in 15-30 mL of sterile water to ensure proper delivery through the NG tube.
A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?
- A. Place the client on their side with their head forward
- B. Call for help
- C. Protect the client's head
- D. Restrain the client
Correct Answer: A
Rationale: Placing the client on their side with their head forward helps maintain an open airway and prevents aspiration.
A nurse is updating a plan of care after evaluating a client who has dysphagia. Which interventions should the nurse include in the plan?
- A. Have the client lie down after meals
- B. Encourage the client to speak while eating
- C. Have the client sit upright for 1 hour following meals
- D. Offer thin liquids with meals
Correct Answer: C
Rationale: Having the client sit upright for 1 hour after meals facilitates swallowing and reduces the risk of aspiration.
A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?
- A. Eye contact
- B. Personal space
- C. Touch
- D. All of the above
Correct Answer: D
Rationale: Eye contact, personal space, and touch are cultural variables that can affect communication.