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A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
- A. Macaroni & cheese
- B. Fresh fruit & whole wheat toast
- C. Rice pudding & ripe bananas
- D. Roast chicken & white rice
Correct Answer: B
Rationale: The correct answer is B: Fresh fruit & whole wheat toast. Fresh fruits are high in fiber, which aids in digestion and helps prevent constipation. Whole wheat toast also contains fiber, promoting regular bowel movements. Macaroni & cheese (A) and rice pudding & ripe bananas (C) are low in fiber and may worsen constipation. Roast chicken & white rice (D) lack sufficient fiber to alleviate constipation.
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An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24hr postop to use an incentive spirometer
- B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift
- C. Providing nasopharyngeal suctioning for a client who has pneumonia
- D. Replacing the cartridge and tubing on a PCA pump
Correct Answer: D
Rationale: The LPN should question assignment D (replacing the cartridge and tubing on a PCA pump) because this task involves medication administration and intravenous therapy, which are typically outside the LPN's scope of practice. LPNs are not trained to handle complex medication delivery systems like PCA pumps, as this requires specialized knowledge and skills that are within the RN's scope of practice. It is crucial for patient safety that tasks are assigned to healthcare providers based on their education, training, and scope of practice to prevent errors and ensure quality care. Assignments A, B, and C are within the LPN's scope of practice and can be safely performed without questioning.
A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention?
- A. Give the client thin liquids.
- B. Instruct the client to tuck her chin when swallowing.
- C. Have the client use a straw.
- D. Encourage the client to lie down and rest after meals.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to tuck her chin when swallowing. This intervention helps prevent aspiration by closing off the airway during swallowing, reducing the risk of food or liquids entering the lungs. Tucking the chin also helps direct the food or liquid down the esophagus. Giving thin liquids (choice A) can increase the risk of aspiration. Using a straw (choice C) may also increase the risk by bypassing the natural protective mechanisms. Encouraging the client to lie down after meals (choice D) can lead to aspiration due to decreased muscle tone and gravity assisting in food or liquid entering the airway.
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all.
- A. Restlessness
- B. Tachypnea
- C. Bradycardia
- D. Confusion
- E. Pallor
Correct Answer: A,B,E
Rationale: Correct Answer: A, B, E
Rationale:
1. Restlessness: Early sign of hypoxemia due to the body's attempt to increase oxygen intake.
2. Tachypnea: Increased respiratory rate compensates for low oxygen levels in the blood.
3. Pallor: Skin paleness indicates poor oxygenation of tissues due to hypoxemia.
Incorrect Choices:
C: Bradycardia - Bradycardia is a late sign of hypoxemia, not an early indication.
D: Confusion - Confusion is a late sign of severe hypoxemia affecting the brain function.
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. What is the nurse's highest assessment priority before performing this procedure?
- A. Check how long the feeding container has been opened.
- B. Verify the placement of the NG tube.
- C. Confirm that the client doesn't have diarrhea.
- D. Make sure the client is alert & oriented.
Correct Answer: B
Rationale: The correct answer is B: Verify the placement of the NG tube. This is the highest assessment priority before instilling enteral feeding to prevent complications like aspiration. The nurse must ensure the NG tube is correctly positioned in the stomach to avoid feeding into the lungs. Checking the length of time the feeding container has been open (A) is important but not as critical as verifying tube placement. Confirming the client doesn't have diarrhea (C) is important for monitoring overall health but not directly related to the procedure. Ensuring the client is alert and oriented (D) is essential but not the priority for this specific procedure.
A nursing instructor is acquainting a group of nursing students w/the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks CNAs may perform, which of the following client activities should she include? Select all.
- A. Bathing
- B. Ambulating
- C. Toileting
- D. Determining pain level
- E. Measuring vital signs
Correct Answer: A, B, C, E
Rationale: The correct answer includes choices A, B, and C because Certified Nursing Assistants (CNAs) are typically responsible for assisting with activities of daily living such as bathing, ambulating, and toileting. These tasks are within the scope of practice for CNAs and are essential for maintaining the comfort and well-being of patients. Choice E, measuring vital signs, is also a common task performed by CNAs as it helps monitor the patient's health status and provides valuable information to the healthcare team. Choices D and F are incorrect as CNAs are not typically responsible for determining pain levels, which is typically done by nurses or physicians, and choice G is not provided. Overall, the correct choices align with the typical responsibilities of CNAs in providing direct patient care and support.