Nokea
The nurse is caring for a client with a history of stroke.
- A. Which intervention is most effective for preventing aspiration in a client with a history of stroke?
- B. Thicken liquids to a nectar consistency.
- C. Encourage small, frequent meals.
- D. Place the client in a supine position for meals.
- E. Administer an antiemetic before meals.
Correct Answer: A
Rationale: Thickening liquids to a nectar consistency slows swallowing, reducing aspiration risk in stroke patients with dysphagia. Small meals help, supine positioning increases risk, and antiemetics are irrelevant.
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A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
- A. Gestational age assessment suggested growth retardation
- B. Meconium was cleared from the airway at delivery
- C. Phototherapy was used to treat Rh incompatibility
- D. The infant received mechanical ventilation for 2 weeks
Correct Answer: D
Rationale: The infant received mechanical ventilation for 2 weeks. Bronchopulmonary dysplasia is often caused by prolonged mechanical ventilation.
A client recovering from acute pancreatitis is started on solid food. Which of the following foods should be avoided?
- A. Vanilla custard
- B. Sponge cake
- C. Sliced peaches
- D. Cereal
Correct Answer: A
Rationale: Vanilla custard is high in fat, which can stimulate pancreatic enzyme release and worsen pancreatitis. Sponge cake, peaches, and cereal are lower in fat and safer.
The nurse is caring for a client who is postoperative day 1 after a mastectomy. Which of the following actions should the nurse prioritize?
- A. Encourage arm exercises on the affected side.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Arm exercises prevent lymphedema and promote mobility post-mastectomy. Options B, C, and D are secondary.
A client is scheduled for a traditional abdominal cholecystectomy.
Which of the following statements, if made by the nurse to the client the night before surgery, is MOST important?
- A. It is important for you to eat foods from every level of the food pyramid and avoid excessive fats in your diet.'
- B. Place the pillow against your abdomen, take three deep breaths, hold your breath, and then cough two or three times.'
- C. There will be a machine available to you after surgery for you to use to continuously receive pain medication.'
- D. You may come back from surgery with a tube in your nose that drains your gall bladder.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each implementation. Is it desired? (1) not most important initially, teaching should be done before discharge (2) correct-should be done every two hours to prevent respiratory complications, splinting prevents abdominal jarring (3) PCA pumps used postoperative but medication is administered intermittently (4) NG tube used to drain stomach, T-tube used to drain common bile duct
A 22 year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?
- A. The patient is excited about being around family again.
- B. The patient's suicide plan has probably progressed.
- C. The patient's plans for the future have been clarified.
- D. The patient's mood is improving.
Correct Answer: B
Rationale: The suicide plan may have been decided.