Nokea
The nurse is caring for a client with a tracheostomy who has an order to begin oral intake. Which of the following actions should the nurse take to decrease the client's risk for aspiration?
- A. Fully inflate the tracheostomy cuff before the client begins to eat.
- B. Encourage the client to use a straw when drinking fluids.
- C. Instruct the client to tilt the head back when swallowing
- D. Provide thickened liquids for the client.
Correct Answer: D
Rationale: Thickened liquids (D) reduce aspiration risk by slowing transit. Inflating the cuff (A) is not always necessary, straws (B) may increase risk, and tilting the head back (C) worsens aspiration.
You may also like to solve these questions
The nurse is teaching a group of parents about gross motor development of a 2-year old. According to the Denver Developmental Screening Test, which behavior is an example of the normal gross motor skill of a 2-year old?
- A. She can pull a toy behind her.
- B. She can copy a horizontal line.
- C. She can build a tower of eight blocks.
- D. She can broad jump.
Correct Answer: A
Rationale: Pulling a toy is a gross motor skill for a 2-year-old per the Denver Test. Copying a line and building a tower of eight blocks are fine motor skills. Broad jumping develops later.
A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply.
- A. Palliative care focuses on quality of life and can be provided at any time
- B. Palliative care is only possible with a terminal diagnosis of ≤ 6 months
- C. Palliative care is provided by a multidisciplinary team
- D. Palliative care is another term for hospice care
- E. Palliative care provides relief from symptoms associated with chronic illnesses
Correct Answer: A,C,E
Rationale: Palliative care aims to improve quality of life and can be provided at any stage of illness (A). It involves a multidisciplinary team to address various needs (C). It also focuses on symptom relief for chronic illnesses (E). Palliative care is not limited to terminal diagnoses (B is incorrect) and is distinct from hospice care, which is specifically for end-of-life (D is incorrect).
The LPN is caring for a woman who delivered a healthy 7-lb baby boy 24 hours ago. Baseline vital signs were blood pressure (BP)=90/64, temperature (T)=97.6°F, pulse (P)=72, and respirations (R)=14. Which finding is of greatest concern?
- A. The woman has red vaginal drainage on her perineal pad.
- B. The woman complains of uterine cramping.
- C. The woman is drinking large amounts of water.
- D. The woman's vital signs are now BP=129/82, T=98.4°F, P=76, and R=16.
Correct Answer: D
Rationale: The significant rise in BP to 129/82 from 90/64 may indicate postpartum complications like preeclampsia, requiring immediate assessment. Red drainage, cramping, and increased water intake are normal postpartum findings.
A client who had a total knee replacement is to be discharged today. Which statement that the client makes indicates a need for further instruction?
- A. When I am walking, I will wear that ugly immobilizer.'
- B. I will sit with my leg elevated.'
- C. I think I understand how to use the continuous passive motion machine.'
- D. I won't put any weight at all on my affected leg.'
Correct Answer: D
Rationale: Total knee replacement typically allows partial weight-bearing with assistance post-surgery; complete non-weight-bearing suggests misunderstanding of mobility instructions.
The nurse is caring for a 10-year-old client with sickle cell disease who is experiencing an episode of acute pain. Which of the following diversional activities would be appropriate for the nurse to offer the client?
- A. putting together a puzzle in the activity room
- B. reading an age-appropriate book
- C. walking down the unit hallways
- D. playing with finger puppets
Correct Answer: B
Rationale: Reading a book (B) is a calm, stationary activity suitable for pain management. Puzzles (A) may require movement, walking (C) could worsen pain, and puppets (D) may be too childish for a 10-year-old.