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The nurse is caring for a client who had a stroke and is experiencing dysphagia. Which of the following nursing actions is the PRIORITY?
- A. Position the client upright during meals.
- B. Offer the client thin liquids to drink.
- C. Provide the client with a soft diet.
- D. Encourage the client to eat quickly.
Correct Answer: A
Rationale: Positioning the client upright during meals reduces the risk of aspiration, a life-threatening complication in dysphagia. Options B, C, and D are inappropriate: thin liquids increase aspiration risk, soft diets are secondary, and eating quickly exacerbates the problem.
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Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: Abruptio placentae causes hemorrhage, leading to fluid volume deficit, a major nursing concern. The other options are incorrectly stated or irrelevant: infection is not typical, ‘potential’ diagnoses are not standard, and fibrinogen depletion is not the primary issue.
The treatment protocol for a client with acute lymphatic leukemia includes Orasone (prednisone), Trexall (methotrexate), and Zantac (ranitidine). The purpose of Zantac is to:
- A. Decrease the secretion of pancreatic enzymes.
- B. Enhance the effectiveness of the methotrexate.
- C. Promote peristalsis.
- D. Prevent a common side effect of prednisone.
Correct Answer: D
Rationale: Zantac (ranitidine) prevents gastric irritation and ulcers, a common side effect of prednisone. It does not affect pancreatic enzymes, methotrexate efficacy, or peristalsis.
An elderly client is admitted to a skilled nursing care facility. When doing a skin assessment, the nurse notes a 3-cm round area of partial-thickness skin loss that looks like a blister on the client's sacrum. The nurse interprets this to be a:
- A. stage I pressure ulcer.
- B. stage II pressure ulcer.
- C. stage III pressure ulcer.
- D. stage IV pressure ulcer.
Correct Answer: B
Rationale: A stage II pressure ulcer involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer, matching the description. Stage I is non-blanchable erythema, stage III involves full-thickness loss, and stage IV extends to muscle/bone.
An elderly client is oriented during the day but becomes disoriented during the evening.
Which of the following nursing actions is MOST appropriate?
- A. Place a clock where the client can see it.
- B. Restrain all four extremities.
- C. Keep a light on in the client's room.
- D. Place the side rails in an upright position.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will provide visual cues, safety is more important (2) inappropriate (3) may be appropriate, but is not priority over answer choice #4 (4) correct-side rails should always be in an upright position for a disoriented client
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?
- A. Oral Coumadin therapy
- B. Heparin 5000 units subcutaneously B.I.D.
- C. Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
- D. Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
Correct Answer: C
Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.