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In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?
- A. An older client who fell yesterday and is now complaining of diplopia.
- B. An adult newly diagnosed with type 1 diabetes and high cholesterol.
- C. A client with pancreatic cancer who is experiencing intractable pain.
- D. An older client post-stroke who is aphasic with right-sided hemiplegia.
Correct Answer: D
Rationale: The best client for the charge nurse to assign to a practical nurse (PN) is an older client post-stroke who is aphasic with right-sided hemiplegia. This client is stable and suitable for care by a PN under supervision. Choices A, B, and C present clients with more complex and acute conditions that would require a higher level of nursing expertise and intervention.
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A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instruction is most important for the nurse to include in the discharge plan?
- A. Explain how to use communication tools.
- B. Teach tracheal suctioning techniques.
- C. Encourage self-care and independence.
- D. Demonstrate how to clean the tracheostomy site.
Correct Answer: B
Rationale: The most important instruction for a client who recently underwent a tracheostomy is to teach tracheal suctioning techniques. Suctioning helps clear secretions and maintain an open airway, which is critical for the client's respiratory function and overall well-being. While communication tools, self-care, and cleaning the tracheostomy site are important aspects of care, ensuring proper suctioning techniques is crucial for preventing complications and ensuring the client's safety.
A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Chest X-ray
- B. Arterial blood gases (ABGs)
- C. Echocardiogram
- D. Electrocardiogram (ECG)
Correct Answer: C
Rationale: The correct answer is C: Echocardiogram. An echocardiogram should be performed first to assess ventricular function and evaluate the cause of shortness of breath and crackles in a client with heart failure. An echocardiogram provides valuable information about the heart's structure and function, helping to identify potential issues related to heart failure. Chest X-ray (Choice A) may be done to assess for changes in heart size or fluid in the lungs but does not directly assess heart function. Arterial blood gases (Choice B) may provide information about oxygenation but do not directly evaluate heart function. An electrocardiogram (Choice D) assesses the heart's electrical activity but does not provide detailed information about ventricular function, which is crucial in heart failure management.
While auscultating a client's heart sounds, which description should the nurse use to document a swishing sound related to blood turbulence or valvular defect?
- A. S1 S2
- B. S1 S2 S3
- C. Murmur
- D. Pericardial friction rub
Correct Answer: C
Rationale: The correct answer is 'C: Murmur.' A murmur is auscultated as a swishing sound associated with blood turbulence caused by the heart or a valvular defect. Choices 'A: S1 S2' and 'B: S1 S2 S3' refer to normal heart sounds, specifically the closure of heart valves. 'D: Pericardial friction rub' is a dry, rubbing or grating sound caused by inflammation of the pericardial sac and is not associated with blood flow or valvular issues.
A client with a tracheostomy is experiencing thick, tenacious secretions. Which intervention should the nurse implement first?
- A. Encourage fluid intake to thin secretions.
- B. Administer a mucolytic agent.
- C. Increase humidity in the client's room.
- D. Perform deep suctioning as needed.
Correct Answer: C
Rationale: Increasing humidity in the client's room is the initial intervention for managing thick, tenacious secretions in a client with a tracheostomy. Adequate humidity helps to hydrate secretions, making them easier to clear, thus improving airway clearance. Encouraging fluid intake (Choice A) can be beneficial but is not the first-line intervention. Administering a mucolytic agent (Choice B) may be considered if increasing humidity alone is insufficient. Performing deep suctioning (Choice D) should be reserved for when other measures like increasing humidity have been ineffective.
Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?
- A. Egg whites, toast, and coffee.
- B. Bran muffin, mixed fruits, and orange juice.
- C. Granola and grapefruit juice.
- D. Bagel with jelly and skim milk.
Correct Answer: D
Rationale: The correct answer is D, 'Bagel with jelly and skim milk.' This choice includes skim milk, a good source of calcium, which is important for osteoporosis management. It also avoids foods that inhibit calcium absorption. Osteoporosis dietary management emphasizes increased calcium intake and reducing foods that hinder calcium absorption. Choice A only provides proteins but lacks calcium. Choice B offers fruits and a bran muffin, but it lacks a good source of calcium. Choice C has granola but misses a significant source of calcium.