Nokea
A patient is receiving chemotherapy and has developed stomatitis. Which of the following dietary recommendations should the nurse make?
- A. Eat salty foods to stimulate salivation.
- B. Avoid spicy foods.
- C. Increase intake of high-fiber foods.
- D. Consume cold foods to soothe the mucosa.
Correct Answer: D
Rationale: Correct choice: Consume cold foods to soothe the mucosa. Cold foods can help soothe the mucosa and reduce discomfort for patients with stomatitis caused by chemotherapy.\nIncorrect choices: A) Salty foods may irritate the mucosa further. B) Spicy foods can increase discomfort and irritation. C) High-fiber foods may be rough and abrasive, exacerbating the condition.
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A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?
- A. Flush the tube with 30 mL of sterile water before each feeding.
- B. Check for gastric residuals every 4 hours.
- C. Elevate the head of the bed to 45 degrees during feedings.
- D. Place the client in the left lateral position during feedings.
Correct Answer: C
Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.
A nurse is assessing a client who is 4 hours postoperative following a total hip arthroplasty. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 118/76 mm Hg
- B. Heart rate of 88/min
- C. Urinary output of 30 mL/hr
- D. Hematocrit 42%
Correct Answer: B
Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.
Which of the following lab values indicates a patient on warfarin is at a therapeutic level?
- A. INR of 1.1
- B. PT of 12 seconds
- C. INR of 2.5
- D. Platelet count of 150,000
Correct Answer: C
Rationale: An INR of 2.5 indicates a therapeutic level for a patient on warfarin. The INR (International Normalized Ratio) is the most accurate way to monitor and adjust warfarin doses. An INR of 1.1 (Choice A) is below the therapeutic range, indicating a need for an increased dose. PT (Prothrombin Time) of 12 seconds (Choice B) is not specific for warfarin therapy monitoring. Platelet count (Choice D) is not directly related to monitoring warfarin therapy.
A patient is 1 day postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Administer aspirin for pain management.
- B. Keep the affected leg in a dependent position.
- C. Flex the affected knee for 2 to 3 minutes every hour.
- D. Apply ice packs to the affected knee.
Correct Answer: D
Rationale: The correct action for a client 1 day postoperative following a total knee arthroplasty is to apply ice packs to the affected knee. Ice packs help reduce swelling and pain in such clients. Administering aspirin is contraindicated due to the risk of bleeding postoperatively. Keeping the affected leg in a dependent position can impair circulation and increase the risk of complications. Flexing the affected knee for extended periods can strain the surgical site and hinder the healing process.
A nurse is teaching a client about home care following cataract surgery. Which of the following statements should the nurse include?
- A. You should wear a protective eye shield while sleeping.
- B. You should avoid bending over to pick things up.
- C. You should apply pressure to your eye if you feel pain.
- D. You should resume wearing your regular glasses immediately.
Correct Answer: A
Rationale: The correct answer is A: 'You should wear a protective eye shield while sleeping.' After cataract surgery, wearing a protective eye shield while sleeping is crucial to prevent accidental injury to the eye. Choice B is incorrect because patients should indeed avoid bending over, but it is not the most important instruction among the options provided. Choice C is incorrect because applying pressure to the eye if pain is felt can be harmful and should not be advised. Choice D is incorrect because patients should not resume wearing their regular glasses immediately post cataract surgery; they should wait until their healthcare provider permits.