Nokea
The nurse is caring for a client who is postprocedure following an endoscopy. Which priority action should the nurse take prior to resuming the client's diet?
- A. Assess the client's oxygenation level
- B. Assess for the return of the client's gag reflex
- C. Have the healthcare provider speak with the client regarding results of the procedure
- D. Start with a soft diet to see if the client will tolerate
Correct Answer: B
Rationale: Assessing the gag reflex (B) ensures safe swallowing post-endoscopy to prevent aspiration before resuming the diet.
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A nurse is conducting a dysphagia screening on a client who was recently extubated. Which assessment finding requires intervention?
- A. Slight cough after sipping water.
- B. Hoarseness of voice during speech.
- C. Reports of mild throat discomfort when swallowing.
- D. Presence of a wet, gurgling cough after drinking water.
Correct Answer: D
Rationale: A wet, gurgling cough after drinking water (D) indicates possible aspiration, requiring immediate intervention to prevent complications like pneumonia. Slight cough (A), hoarseness (B), and mild discomfort (C) are less urgent.
Which of the following clients does the nurse suspect would benefit most from placement of a nasogastric tube?
- A. A 9-year-old client with a femur fracture.
- B. An 82-year-old client with congestive heart failure.
- C. A 65-year-old client on dialysis.
- D. A 52-year-old client with leukemia who is receiving chemotherapy.
Correct Answer: D
Rationale: A client receiving chemotherapy (D) may experience severe nausea and vomiting, necessitating an NG tube for decompression or feeding. The other conditions are less likely to require NG tube placement.
The nurse is caring for a client receiving total parenteral nutrition (TPN) through a central line. The nurse plans on taking which appropriate action?
- A. Inserting an indwelling urinary catheter.
- B. Weighing the client in the morning before the first void.
- C. Placing a mask on the client before changing the central line dressing.
- D. Establishing continuous cardiac monitoring.
Correct Answer: B
Rationale: Weighing the client daily (B) monitors fluid balance and nutritional status, critical for TPN management. Catheters (A), masks (C), and cardiac monitoring (D) are not routinely required unless indicated.
The nurse is teaching a client about their newly established colostomy. Which of the following statements by the client would require follow-up?
- A. I will call my primary healthcare provider (PHCP) immediately if my stoma becomes bluish.
- B. I should slowly introduce high-fiber foods in my diet.
- C. I must always wear a pouch over my stoma.
- D. I should clean the skin around my stoma with rubbing alcohol.
Correct Answer: D
Rationale: Using rubbing alcohol (D) can irritate the skin around the stoma. Options A, B, and C are appropriate for colostomy care.
The nurse observes a newly hired nurse care for a client with a colostomy. Which action by the newly hired nurse requires follow-up? Select all that apply.
- A. Empties the pouch when it is one-third to one-half full.
- B. Washes the surrounding skin with moisturizing soap.
- C. Indicates that the reddish appearance of the stoma as normal.
- D. Applies sterile gloves prior to changing the device.
- E. Applies isopropyl alcohol to the surrounding skin to promote adherence with the wafer.
Correct Answer: B,D,E
Rationale: Using moisturizing soap (B) can interfere with appliance adhesion, sterile gloves (D) are unnecessary as clean gloves suffice, and isopropyl alcohol (E) can irritate the skin. Emptying the pouch appropriately (A) and recognizing a normal stoma (C) are correct.