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The nurse is teaching feeding protocol to the spouse of a client who experienced a severe stroke. Which statement by the spouse indicates a need for further explanation by the nurse?
- A. I will not let him use a straw.
- B. I will turn on the television during meals.
- C. Instead of whole pills, I will crush the pill and place it in custard.
- D. He will sit up for a half hour after eating.
Correct Answer: B
Rationale: Turning on the television during meals can distract the client, increasing the risk of aspiration, and requires further teaching. Other statements are appropriate.
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The nurse is seeing a client and her 11-month-old baby in the clinic for a wellness checkup. Which comment by the mother would prompt the nurse to notify the health care provider?
- A. She loves to play peekaboo.
- B. She loves to look at herself in the mirror.
- C. She does not like to be around strangers.
- D. She does not try to crawl when I put her down.
Correct Answer: D
Rationale: Lack of crawling at 11 months may indicate developmental delay, requiring provider evaluation. Other behaviors are age-appropriate.
The nursing assistant is taking vitals for a client on mechanical ventilation. Which of the following findings should the nursing assistant report to the nurse immediately?
- A. respiratory rate 26 breaths/minute
- B. heart rate 82 beats/minute
- C. blood pressure 152/86 mmHg
- D. temperature 102.1°F
Correct Answer: D
Rationale: Fever (102.1°F) in a ventilated client suggests infection (e.g., ventilator-associated pneumonia), requiring immediate reporting.
A nurse is assessing a 33-year-old patient who underwent a cholecystectomy 18 hours prior. The nurse notes 500 mL of greenish-brown fluid has drained from the T-tube postoperatively. The nurse should
- A. chart these findings and reassess on the next rounding.
- B. call the physician and report the drainage.
- C. flush and irrigate the tube.
- D. chart these findings and indicate an infection is suspected.
Correct Answer: A
Rationale: Greenish-brown drainage (bile) from a T-tube post-cholecystectomy is expected (up to 500-1000 mL/day initially). The nurse should document and monitor, not assume infection or intervene unnecessarily.
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
- A. Crying
- B. Wakefulness
- C. Jitteriness
- D. Yawning
Correct Answer: C
Rationale: Jitteriness in a newborn of a diabetic mother may indicate hypoglycemia, which requires immediate nursing intervention to prevent complications.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.