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A nurse receives report on a group of clients. Which client should the nurse assess first?
- A. A preschool-age child with a harsh cough, expiratory wheezes, and mild intercostal retractions
- B. A toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak
- C. A toddler with a barking cough, infrequent inspiratory stridor, and oxygen saturation of 94% on room air
- D. An infant with an axillary temperature of 100.1 F (37.8 C) who is tugging at the left ear
Correct Answer: B
Rationale: The toddler with circumoral cyanosis, distress, and inability to speak suggests a potential airway obstruction, a life-threatening emergency requiring immediate assessment. Other clients show less acute symptoms.
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The family of a frail elderly man who is bedridden asks the nurse what they can do to prevent bedsores. Which response by the nurse is best?
- A. Get him out of bed at least once a day.'
- B. Turn him every two hours.'
- C. Rub his buttocks and apply lotion several times a day.'
- D. Change the sheets every day.'
Correct Answer: B
Rationale: Turning every two hours relieves pressure on bony prominences, preventing pressure ulcers. Getting out of bed may be infeasible, and rubbing or sheet changes are less effective.
The nurse has delegated care of a client who is very hard of hearing to an unlicensed person. Which of the following would be the least helpful information to give to the unlicensed person to better facilitate communications with the client?
- A. Reduce background noise.
- B. Adjust the hearing aid.
- C. Anticipate what the client may say and finish the statement for the client.
- D. Face the client when speaking to the client.
Correct Answer: C
Rationale: Anticipating and finishing statements risks miscommunication and frustration, least helpful for effective communication with a hearing-impaired client.
The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply.
- A. Check gastric residual every 12 hours
- B. Keep head of the bed at ≥30 degrees
- C. Maintain endotracheal cuff pressure
- D. Monitor for abdominal distension every 4 hours
- E. Use caution when administering sedatives
Correct Answer: B,C,D,E
Rationale: Elevating the head of the bed (≥30 degrees) reduces reflux, proper cuff pressure seals the airway, monitoring distension detects feed intolerance, and cautious sedation prevents respiratory depression. Residual checks every 4-6 hours are standard, not 12.
An adult is admitted with Guillain-Barré syndrome. On day 3 of hospitalization, the client's muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in the nursing care plan at this time is to prevent which problem?
- A. Aspiration pneumonia
- B. Decubitus ulcers
- C. Bladder distention
- D. Hypertensive crisis
Correct Answer: A
Rationale: Difficulty swallowing increases aspiration risk, making aspiration pneumonia the priority. Other complications are secondary in this acute phase.
The nurse is reinforcing education to a group of clients who are pregnant or planning pregnancy. Which of the following client statements about alcohol use in pregnancy indicate a need for further education? Select all that apply.
- A. As long as I don't binge drink, an occasional glass of wine is fine.
- B. I drank alcohol heavily before realizing I was pregnant, so there is no benefit to quitting now.
- C. If I drink alcohol, my baby may have withdrawal after birth but no permanent damage.
- D. It is important to stop drinking while I am trying to conceive.
- E. Third-trimester alcohol use is less harmful because the baby is fully developed.
Correct Answer: A,B,C,E
Rationale: No amount of alcohol is safe during pregnancy, as it can cause fetal alcohol spectrum disorders. Quitting at any point reduces harm. Alcohol can cause permanent damage, not just withdrawal. Third-trimester exposure still risks brain development. Stopping preconception is correct.