Nokea
The client is at risk for ___ as evidenced by the client's ___
- A. Aspiration
- B. Dysphagia
Correct Answer: A,B
Rationale: A: Dysphagia increases aspiration risk. B: Food stuck in mouth and hoarseness indicate swallowing difficulty.
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The client is at risk for developing ___ as evidenced by the client's ___
- A. Infection
- B. WBC count
Correct Answer: A,B
Rationale: A: Chemotherapy lowers immunity, increasing infection risk. B: Decreased WBC count (4,000/mm³) indicates leukopenia.
A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus. When removing personal protective equipment, which of the following pieces should the nurse remove first?
- A. Gown
- B. Goggles
- C. Mask
- D. Gloves
Correct Answer: D
Rationale: Gloves are removed first as they are the most contaminated, reducing spread.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply antiseptic ointment to the tip of my penis.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will clamp the tube when I go for a walk.
Correct Answer: B
Rationale: Keeping the drainage bag below waist level prevents backflow and reduces infection risk.
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Client instructed on self-care needs.
- B. Episiotomy approximated. 3 cm (1.18 in) in length.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: B
Rationale: Documenting the status of the episiotomy provides essential information regarding healing and recovery, a priority in postpartum care.
The findings in the client's medical record indicate ___ and ___.
- A. Hyperglycemia
- B. Dehydration
Correct Answer: A,B
Rationale: Hyperglycemia: Symptoms of lethargy, thirst, and frequent urination with parenteral nutrition suggest elevated glucose levels. Dehydration: Thirst and frequent urination indicate fluid loss, a risk with parenteral nutrition if not balanced.