Nokea
The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:
- A. Offer thin liquids
- B. Position the client flat for meals
- C. Thicken liquids
- D. Use a straw for fluids
Correct Answer: C
Rationale: Thickening liquids reduces aspiration risk in dysphagia post-stroke. Thin liquids, flat positioning, and straws increase aspiration risk.
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The elderly client is being discharged following a total knee replacement. To facilitate independence, the nurse should instruct the client/family to do which of the following?
- A. Use an elevated commode seat.
- B. Remove throw rugs from the floor.
- C. Install grab bars in the bathroom.
- D. Wear a medic alert monitor.
- E. Leave the nightlight on during resting hours.
- F. Apply foot protectors to the heels.
- G. Place the walker at the bedside.
Correct Answer: A, B, C, D, E, G
Rationale: Elevated commode seats (A), removing rugs (B), grab bars (C), medic alert monitors (D), nightlights (E), and bedside walkers (G) promote safety and independence. Foot protectors (F) are unrelated to mobility, and elevated side rails (H) may trap the client, increasing fall risk.
The physician orders Zestril (lisinopril) and Lasix (furosemide) to be administered at the same time to a client with hypertension. The nurse should:
- A. Question the order
- B. Administer the medications as ordered
- C. Administer the medications separately
- D. Contact the pharmacy
Correct Answer: B
Rationale: Lisinopril (an ACE inhibitor) and furosemide (a diuretic) are commonly prescribed together for hypertension to reduce blood pressure synergistically. Administering them as ordered is appropriate as there is no contraindication to concurrent use.
Which skin assessment in a newborn indicates a need for follow-up?
- A. Miliaria rubra
- B. Erythema toxicum
- C. Mongolian spots
- D. Jaundice at birth
Correct Answer: D
Rationale: Jaundice at birth is abnormal and may indicate hemolytic disease liver dysfunction or other serious conditions requiring immediate follow-up. Miliaria rubra erythema toxicum and Mongolian spots are benign and common in newborns.
Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
- A. Fine hand tremor, headache, mental dullness
- B. Vomiting, impaired consciousness, decreased blood pressure
- C. Polyuria, polydipsia, edema
- D. Gastric irritation, nausea, diarrhea
Correct Answer: B
Rationale: These symptoms of lithium toxicity are usually dose related.
Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:
- A. Tetralogy of Fallot
- B. Ventricular septal defect
- C. Patent ductus arteriosus
- D. Transposition of the great arteries
Correct Answer: A
Rationale: Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood to reach the systemic circulation. A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the Systemic circulation. In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.