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The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?
- A. Cleanse the tongue and mouth with swabs.
- B. Administer a topical analgesic per protocol.
- C. Obtain a soft diet for the client.
- D. Encourage frequent mouth care.
Correct Answer: B
Rationale: Administering a topical analgesic provides immediate pain relief for mucositis, addressing the client's discomfort first before implementing other supportive measures like diet or mouth care.
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An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?
- A. Demonstrate the use of visual scanning during meals to the client and family.
- B. Explain that weight loss will be reversed after the acute phase of the stroke has ended.
- C. Suggest that the family bring foods from home that the client enjoys eating.
- D. Encourage the family to offer to feed the client when she does not eat her entire meal.
Correct Answer: A
Rationale: Teaching visual scanning compensates for visual perception deficits post-CVA, enabling the client to see all food on the tray, addressing the root cause of poor intake and improving nutrition.
The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?
- A. Provide the first medication prescribed for pain management.
- B. Review medical records to obtain pain tolerance expectations.
- C. Wait until the client is awake before providing pain management.
- D. Attempt to obtain a self-report of pain level from the client.
Correct Answer: A
Rationale: Providing the prescribed pain medication first prevents pain escalation in a sedated client, using behavioral indicators like vital signs to guide administration, as self-reporting may be unreliable.
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
- A. Corticosteroid cream was applied to eczema.
- B. A grandson and his new dog recently visited.
- C. An old friend with eczema came for a visit.
- D. Recently received an influenza immunization.
Correct Answer: B
Rationale: Exposure to a new dog may introduce allergens like dander, triggering an eczema flare-up, making this information critical for identifying the cause of the exacerbation.
An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
- A. Clear, dark amber-colored urine.
- B. Improved level of consciousness.
- C. Prothrombin time within normal limits.
- D. Decreased abdominal girth.
Correct Answer: D
Rationale: Decreased abdominal girth reflects reduced ascites, confirming the effectiveness of low sodium diet and albumin infusions in managing fluid retention in hepatic failure.
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
- A. Reorient to day and time frequently.
- B. Apply soft wrist restraints bilaterally.
- C. Administer a PRN dose of lorazepam.
- D. Turn the television on for distraction.
- E. Present a calm, supportive demeanor.
Correct Answer: A,C,E
Rationale: Reorienting, administering lorazepam, and presenting a calm demeanor help manage postoperative delirium symptoms like hallucinations, ensuring patient safety and comfort.