Nokea
An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?
- A. Assessing client's breath sounds every 2 hours
- B. Placing client in the side lying position in bed
- C. Titrating client's oxygen to maintain saturation 93%
- D. Turning and repositioning the client every 2 hours
Correct Answer: B
Rationale: The side-lying position (B) reduces aspiration risk by preventing reflux into the airway, especially in clients with altered consciousness. Assessing breath sounds (A), oxygen titration (C), and repositioning (D) are supportive but less effective for prevention.
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A client has many delusions. As the nurse helps the client prepare for breakfast the client comments 'Don't waste good food on me. I'm dying from this disease I have.' The appropriate response would be
- A. You need some nutritious food to help you regain your weight.'
- B. None of the laboratory reports show that you have any physical disease.'
- C. Try to eat a little bit, breakfast is the most important meal of the day.'
- D. I know you believe that you have an incurable disease.'
Correct Answer: D
Rationale: This response does not challenge the client’s delusional system and thus forms an alliance by providing reassurance of desire to help the client.
An adult has been taking captopril (Capoten) for hypertension. The client tells the nurse that he has a dry cough and sometimes gets dizzy when he stands up. What conclusions should the nurse make regarding this client?
- A. The client is having severe side effects and should discontinue the drug until after he sees his physician.
- B. Dizziness is a common side effect of antihypertensives. The cough is probably unrelated to the medication.
- C. A dry cough is a common side effect of angiotensin-converting enzyme (ACE) inhibitors. The client should stand up slowly to avoid orthostatic hypotension, a common side effect of antihypertensives.
- D. Cough is a serious side effect and usually results in discontinuing the medication. The dizziness will get better with time.
Correct Answer: C
Rationale: Dry cough and orthostatic hypotension are common ACE inhibitor side effects; slow position changes mitigate dizziness, and cough may require evaluation.
A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider?
- A. Diarrhea, vomiting, and mild tremor
- B. Dry mouth and mild thirst
- C. Hyperactivity and auditory hallucinations
- D. Lithium level of 1.3 mEq/L (1.3 mmol/L)
Correct Answer: A
Rationale: Diarrhea, vomiting, and tremor (A) suggest lithium toxicity, requiring immediate reporting. Dry mouth (B) is common, hallucinations (C) are unrelated, and a lithium level of 1.3 (D) is within therapeutic range.
The nurse is caring for a client who has acute pericarditis. Which of the following findings would be a priority to follow up?
- A. chest pain that is worse with deep inspiration
- B. muffled heart tones and jugular venous distension
- C. pericardial friction rub auscultated at the left sternal border
- D. temperature of 100.7 F (38.2 C) and a nonproductive cough
Correct Answer: B
Rationale: Muffled heart tones and jugular venous distension (B) suggest pericardial effusion or tamponade, a life-threatening complication requiring urgent follow-up. Chest pain (A) and friction rub (C) are expected, and mild fever (D) is less urgent.
The nurse is reviewing the medication administration record for a 70-year-old client. Which of the following prescribed medications places the client at increased risk for injury? Select all that apply.
- A. diphenhydramine
- B. amitriptyline
- C. simvastatin
- D. famotidine
- E. diazepam
Correct Answer: A,B,E
Rationale: Diphenhydramine (A), amitriptyline (B), and diazepam (E) cause sedation or confusion, increasing fall risk in the elderly. Simvastatin (C) and famotidine (D) do not significantly increase injury risk.