Nokea
A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?
- A. Elevating the head of the client's bed to 30 degrees during mealtime
- B. Withholding fluids until the end of the meal
- C. Providing a 10-minute rest period prior to meals
- D. Instructing the client to place her chin toward her chest when swallowing
Correct Answer: D
Rationale: The correct technique for a client with dysphagia is to instruct them to place their chin toward their chest when swallowing. This action helps to close off the airway during swallowing, reducing the risk of aspiration. Elevating the head of the client's bed to 30 degrees during mealtime helps prevent aspiration, but this is not the responsibility of the AP. Withholding fluids until the end of the meal can lead to dehydration and is not a recommended practice. Providing a 10-minute rest period prior to meals is not specifically related to improving swallowing safety for clients with dysphagia.
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A nurse working on a med-surg unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
- A. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
- B. A client with type 1 DM who uses an insulin pump
- C. A client who is receiving heparin and has an aPTT of 34 seconds
- D. A client with orthostatic hypotension receiving IV fluids
Correct Answer: C
Rationale: The nurse should schedule an interdisciplinary conference for a client who is receiving heparin and has an aPTT of 34 seconds to ensure comprehensive care coordination. In this case, the need for a conference may be to discuss potential adjustments in heparin therapy, monitor for adverse effects, or ensure proper anticoagulation levels. Choices A, B, and D do not specifically indicate the need for interdisciplinary collaboration related to the client's condition or treatment. Therefore, they are not the priority for scheduling an interdisciplinary conference.
A nurse manager is leading a discussion about ethical dilemmas. Which of the following situations should the nurse manager include as an example of an ethical dilemma?
- A. A visitor experiences a minor burn after spilling coffee
- B. A client receives an operation on the wrong side of her body
- C. A parent wants her 14-year-old adolescent to receive radiation treatment against his will
- D. A nurse witnesses another nurse administer an incorrect medication
Correct Answer: C
Rationale: An ethical dilemma involves a situation where moral principles conflict, such as in the case of a parent wanting their adolescent to receive treatment against their will. In option A, a minor burn from spilled coffee does not present a conflict of moral principles. Option B describes a medical error, not necessarily a conflict of moral principles. Option D involves an issue of professional practice and patient safety but does not inherently pose a conflict of moral principles.
A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
- A. A client who reports right-sided flank pain and is diaphoretic
- B. A client who has active bleeding from a puncture wound of the left groin area
- C. A client who has a raised red skin rash on his arms, neck, and face
- D. A client who reports shortness of breath and left neck and shoulder pain
Correct Answer: D
Rationale: The correct answer is D because shortness of breath with referred pain may indicate a serious condition, such as a cardiac event or pulmonary embolism, making this the highest priority. Option A, flank pain with diaphoresis, could suggest kidney-related issues but is not as immediately life-threatening as compromised breathing. Option B, active bleeding, though serious, can usually be controlled with proper interventions. Option C, a raised red skin rash, may indicate an allergic reaction but is not as urgent as respiratory distress with neck and shoulder pain.
Which technique or method is used to determine whether or not the patient has an irregular pulse?
- A. Apical pulse
- B. Inspection
- C. Auscultation
- D. Percussion
Correct Answer: A
Rationale: An apical pulse check is used to determine if the patient has an irregular pulse. The apical pulse is located at the point of maximal impulse (PMI) and is assessed using a stethoscope. Choice B, inspection, involves visual examination and is not used to assess pulse irregularities. Choice C, auscultation, involves listening to internal sounds using a stethoscope, which can be used to assess heart sounds but not specifically for pulse irregularities. Choice D, percussion, is a technique used to assess the density of body tissues or detect abnormal masses and is not used to determine pulse irregularities.
Your 54-year-old male HIV-positive patient has just expired. How should you care for this deceased patient?
- A. Bathe the patient, but it is still necessary to use standard precautions because the patient is deceased.
- B. Place the patient in a negative pressure isolated area of the morgue.
- C. Double shroud the patient to prevent the spread of infection.
- D. Bathe the patient using the same standard precautions you used when he was alive.
Correct Answer: D
Rationale: Even after a patient has expired, standard precautions should be maintained to prevent the spread of infection. Bathing the deceased patient should be done using the same standard precautions followed when the patient was alive. This includes using personal protective equipment and following proper infection control procedures. Choices A, B, and C are incorrect because standard precautions must still be adhered to even after the patient has passed away to ensure safety and prevent the transmission of infections.