Nokea
Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene?
- A. Placing the client on the back with a small pillow under the head.
- B. Keeping portable suctioning equipment at the bedside.
- C. Opening the client's mouth with a padded tongue blade.
- D. Cleaning the client's mouth and teeth with a toothbrush.
Correct Answer: A
Rationale: Placing the client on their back increases the risk of aspiration, especially in stroke patients with impaired swallowing. Suction equipment, padded tongue blades, and toothbrushing are appropriate for safe oral hygiene.
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A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client:
- A. Adds dried fruit to cereal and baked goods.
- B. Cooks tomato-based foods in iron pots.
- C. Drinks coffee or tea with meals.
- D. Adds vitamin C to all meals.
Correct Answer: C
Rationale: Drinking coffee or tea with meals inhibits iron absorption due to tannins, which bind to iron and reduce its bioavailability. This indicates a lack of understanding of nutritional counseling for anemia, as the client should avoid these beverages during meals. Adding dried fruit (iron source), cooking in iron pots (increases iron content), and consuming vitamin C (enhances iron absorption) are appropriate strategies.
A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to:
- A. Call for the physician.
- B. Start an I.V. line.
- C. Obtain a portable chest radiograph.
- D. Draw blood for laboratory studies.
Correct Answer: A
Rationale: Indigestion in a client with cardiac risk factors may indicate an MI. Calling the physician promptly ensures rapid evaluation and intervention, such as ECG or medications.
What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis?
- A. Don't worry. It's normal to feel that way.'
- B. Your friends are probably afraid of contracting hepatitis from you.'
- C. I'm sure you're imagining that!'
- D. Tell me more about your feelings of isolation.'
Correct Answer: D
Rationale: Encouraging the client to express feelings (D) fosters therapeutic communication and addresses emotional needs. Dismissing feelings (A, C) or assuming others' fears (B) is non-therapeutic and unhelpful.
Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation?
- A. Bradycardia.
- B. Hypertension.
- C. Increasing abdominal girth.
- D. Petechiae.
Correct Answer: C
Rationale: Internal bleeding in DIC can cause blood accumulation in the abdominal cavity, leading to increasing abdominal girth. Bradycardia and hypertension are not typical, and petechiae are associated with cutaneous bleeding.
A client arrives from surgery to the postanesthesia care unit. Which of the following respiratory assessments should the nurse complete first?
- A. Oxygen saturation.
- B. Respiratory rate.
- C. Breath sounds.
- D. Airway flow.
Correct Answer: A
Rationale: Oxygen saturation is the first respiratory assessment in the PACU, as it quickly indicates oxygenation status and guides further interventions if hypoxia is detected.