Nokea
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate?
- A. Maintaining an upright position.
- B. Restricting the diet to liquids until swallowing improves.
- C. Introducing foods on the unaffected side of the mouth.
- D. Keeping distractions to a minimum.
Correct Answer: B
Rationale: Restricting the diet to liquids increases aspiration risk, as liquids are harder to control. Upright positioning, using the unaffected side, and minimizing distractions reduce aspiration risk.
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The nurse is caring for a client requiring an emergent transfusion of packed red blood cells. The nurse checks the blood bank, but the only available blood is O + (positive). The client's blood type is A+ (positive). What is the nurse's most appropriate action?
- A. Arrange for a cross-match between the available blood and the client's blood.
- B. Call the other blood banks and ask if they have blood units available with the client’s blood type.
- C. Notify the physician that there is no available blood in the blood bank.
- D. Call the client’s family and tell them that he needs blood.
Correct Answer: A
Rationale: In an emergency, O+ blood can be safely transfused to an A+ client, as O+ is the universal donor for red blood cells. Arranging for a cross-match ensures compatibility and is the most appropriate action. Contacting other blood banks or notifying the physician delays care, and calling the family is inappropriate.
Which of the following is not a risk factor for the development of atherosclerosis?
- A. A family history of early heart attack.
- B. Late onset of puberty.
- C. Total blood cholesterol level greater than 220 mg/dL.
- D. Elevated fasting blood glucose concentration.
Correct Answer: B
Rationale: Late onset of puberty is not a risk factor for atherosclerosis. Family history, high cholesterol, and elevated glucose are established risk factors.
A 62-year-old male client with prostate cancer is scheduled for a radical prostatectomy. He expresses concern about how the surgery will affect his sexual function. The nurse's best response is to:
- A. Explain that sexual function will not be affected.
- B. Discuss that erectile dysfunction is a possible side effect.
- C. Suggest that he avoid sexual activity post-surgery.
- D. Assure him that libido will return immediately after recovery.
Correct Answer: B
Rationale: Radical prostatectomy often affects the nerves responsible for erections, making erectile dysfunction a possible side effect. Discussing this honestly prepares the client for potential outcomes and management options.
The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:
- A. Correct water and electrolyte imbalances.
- B. Allow the gastrointestinal tract to rest.
- C. Provide supplemental vitamins and minerals.
- D. Ensure adequate caloric and protein intake.
Correct Answer: D
Rationale: Major burn injuries significantly increase metabolic demands, requiring high caloric and protein intake to support healing and tissue repair. TPN is primarily used to meet these nutritional needs when oral or enteral feeding is not feasible.
Postoperative nursing care for a client after an appendectomy should include which of the following?
- A. Administering sitz baths four times a day.
- B. Noting the first bowel movement after surgery.
- C. Limiting the client's activity to bathroom privileges.
- D. Measuring abdominal girth every 2 hours.
Correct Answer: B
Rationale: Noting the first bowel movement after an appendectomy is important to confirm the return of bowel function. Sitz baths, limited activity, or measuring girth are not standard post-appendectomy care. CN: Physiological adaptation; CL: Synthesize