Nokea
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?
- A. Encourage the client to drink more slowly
- B. Stop feeding and assess for signs of aspiration
- C. Elevate the head of the bed further
- D. Teach coughing and deep breathing exercises
Correct Answer: B
Rationale: When an older adult with aspiration pneumonia coughs while attempting to drink, it may indicate aspiration. Aspiration can lead to serious complications. Therefore, the appropriate intervention for the nurse in this situation is to stop feeding immediately and assess the client for signs of aspiration. Encouraging the client to drink more slowly (Choice A) may not address the risk of aspiration. Elevating the head of the bed further (Choice C) is generally beneficial to prevent aspiration but is not the priority when immediate assessment is needed. Teaching coughing and deep breathing exercises (Choice D) is not appropriate when the client is actively coughing during feeding and requires immediate assessment for potential aspiration.
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In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client becomes lethargic. Which assessment data should the nurse obtain next?
- A. Pulse oximetry
- B. Blood glucose
- C. Arterial blood gases
- D. Serum electrolytes
Correct Answer: B
Rationale: Deep, rapid respirations (Kussmaul respirations) and lethargy are signs of diabetic ketoacidosis (DKA), which occurs in uncontrolled type 1 diabetes. Checking the blood glucose is the priority to confirm hyperglycemia and guide immediate treatment. Pulse oximetry is not the priority in this situation as the issue is related to altered glucose levels, not oxygenation. Arterial blood gases and serum electrolytes may be important later in the management of DKA but are not the initial priority compared to confirming and addressing the hyperglycemia.
The nurse is providing care for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse implement to prevent complications associated with the tube?
- A. Elevate the head of the bed to 15 degrees during feedings
- B. Aspirate gastric contents before administering medications
- C. Clamp the tube between feedings
- D. Flush the tube with water before and after feedings
Correct Answer: D
Rationale: Flushing the PEG tube with water before and after feedings helps prevent clogging and maintains tube patency. Proper flushing is essential for avoiding complications related to tube blockages. Elevating the head of the bed is important for preventing aspiration during and after feedings, not specifically related to PEG tube complications. Aspirating gastric contents before administering medications is not routinely recommended for PEG tube care. Clamping the tube between feedings can lead to tube occlusion and is not a standard practice in PEG tube care.
An adult client with a broken femur reports muscle spasms. What action should the nurse implement while awaiting surgery?
- A. Check the client's most recent electrolyte levels.
- B. Administer a PRN dose of muscle relaxant.
- C. Reduce the weight on the traction device.
- D. Encourage oral fluid intake to relieve muscle tension.
Correct Answer: D
Rationale: The correct action for the nurse to implement while awaiting surgery for a client with muscle spasms due to a broken femur is to encourage oral fluid intake to relieve muscle tension. Dehydration can exacerbate muscle spasms, so increasing fluid intake can help alleviate them. Checking electrolyte levels may not directly address muscle spasms in this situation. Administering a muscle relaxant should be based on a healthcare provider's prescription, and traction weight adjustments should only be made by the provider overseeing the client's care.
Before administering digoxin to a client with heart failure, what is the most important assessment for the nurse to perform?
- A. Check the client's blood pressure
- B. Monitor the client's heart rate
- C. Assess the client's respiratory rate
- D. Review the client's potassium level
Correct Answer: B
Rationale: The correct answer is to monitor the client's heart rate. Digoxin slows the heart rate, so it is crucial to assess the heart rate before administering the medication. If the heart rate is below 60 beats per minute, the dose should be held, and the healthcare provider should be notified. Checking the blood pressure (Choice A) is important but not as crucial as monitoring the heart rate in this case. Assessing the respiratory rate (Choice C) is not directly related to the action of digoxin. Reviewing the client's potassium level (Choice D) is important for clients taking digoxin due to the risk of hypokalemia, but assessing the heart rate takes priority.
In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care?
- A. Evaluate closest proximal pulse.
- B. Note amount and color of wound drainage.
- C. Observe for swelling around the stump.
- D. Assess skin elasticity of the stump.
Correct Answer: A
Rationale: After an amputation, monitoring the pulse closest to the stump is crucial in evaluating tissue perfusion and the overall health of the limb. Swelling and changes in perfusion can indicate complications such as blood clots or infection. Assessing the proximal pulse helps the nurse ensure adequate blood flow to the remaining limb, thereby preventing further complications. Choices B, C, and D are less directly related to monitoring tissue perfusion in this scenario and are more focused on wound healing and stump care.