Nokea
The nurse is observing a student nurse feed a client requiring aspiration precautions. The nurse should intervene if the student
- A. Asks the client to remain sitting upright for at least 30 to 60 minutes after a meal.
- B. Reminds the client to tilt their head backward when eating and drinking.
- C. Avoids mixing foods of different textures in the same mouthful.
- D. Places salt and pepper on the client's food at their request.
Correct Answer: B
Rationale: Tilting the head backward increases aspiration risk. Upright positioning, avoiding mixed textures, and seasoning food are appropriate.
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The nurse is providing preoperative teaching to a client scheduled for a pneumonectomy. Which of the following statements should the nurse make to the client?
- A. You must lay on your nonoperative side immediately following this surgery
- B. You can expect your lung function to return to normal within two to six hours
- C. You will want to avoid coughing after this surgery as you will be suctioned using a catheter
- D. You will be encouraged to get up and walk the same day as your surgery
Correct Answer: D
Rationale: Early ambulation post-pneumonectomy promotes lung expansion, prevents complications like pneumonia, and aids recovery. Lying on the nonoperative side is not universally required, lung function does not return to normal in hours, and coughing is encouraged to clear secretions, not avoided.
A nurse is taking care of a client undergoing cerebral angiography. Which statement by the client would require immediate follow-up?
- A. I feel like I'm going to vomit.
- B. I hope my results are okay.
- C. It's getting a bit hot in here.
- D. My throat is getting a bit itchy, and my eyes are getting watery.
Correct Answer: D
Rationale: Itchy throat and watery eyes suggest an allergic reaction to the contrast dye, requiring immediate intervention. Nausea, hopefulness, and feeling warm are less urgent.
The nurse observes sparks fly from a client's bathroom light. Which action should the nurse take first?
- A. Obtain a fire extinguisher
- B. Close the bathroom door
- C. Remove the client from the room
- D. Activate the fire alarm
Correct Answer: C
Rationale: Removing the client from the room prioritizes safety in a potential fire hazard. Other actions follow after ensuring client safety.
The nurse is caring for a client who is two days postoperative following a right femoral popliteal bypass surgery. The client reports worsening pain, and the assessment showed swelling and ecchymosis at the incision sites. The nurse should initially
- A. Apply pressure to sites with sandbag
- B. Palpate pedal pulses
- C. Assess for signs of claudication
- D. Apply warm compress to incision sites
Correct Answer: B
Rationale: Worsening pain, swelling, and ecchymosis at the incision sites suggest possible complications such as hematoma or compromised vascular flow. Palpating pedal pulses is the priority to assess the patency of the bypass graft and ensure adequate distal perfusion. Applying pressure or warm compresses could exacerbate bleeding or swelling, and claudication assessment is less urgent than confirming vascular integrity.
The nurse observes a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Which of the following should the nurse assess in the patient?
- A. Pain
- B. Anxiety
- C. Depression
- D. Fluid volume deficit
Correct Answer: A
Rationale: Stooped gait, grimacing, and gasping suggest pain, requiring immediate assessment. Anxiety, depression, or fluid deficit are less likely based on these signs.