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The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.Which action by the UAP should the nurse recognize indicates the need for additional teaching?
- A. Places food on the unaffected side of the mouth.
- B. Raises the head of the bed to 80 degrees.
- C. Positions the head with the chin tilted slightly downward.
- D. Allows 30 minutes of rest before feeding.
Correct Answer: B
Rationale: Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort.
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The nurse is caring for a client who has only months predicted to live. The client avoids questions regarding plans for care.What is the next approach for the nurse to use when discussing end of life issues with the client?
- A. Ask questions in a vague, nonspecific format.
- B. Get the most difficult questions over with first.
- C. Begin with questions that are less sensitive in nature.
- D. Share personal values to put the client at ease.
Correct Answer: C
Rationale: Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive. A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed.
While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion.Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
- A. Hematocrit.
- B. Serum.
- C. Blood PT level.
- D. Neutrophil count.
Correct Answer: D
Rationale: Neutrophils are a type of white blood cell that play a key role in fighting infections. An elevated neutrophil count can indicate the presence of an infection. Therefore, before reporting the finding of a red, tender, and swollen wound at the site of the lesion to the healthcare provider, the nurse should note the client's neutrophil count.
Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).
- A. Solid with red streaks.
- B. Formed but solid.
- C. Brown liquid.
- D. Tarry appearance.
- E. Multiple hard pellets.
Correct Answer: A,C,D,E
Rationale: Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up. Multiple hard pellets may indicate constipation or dehydration and should be addressed.
The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.Which intervention should the nurse implement next?
- A. Ask the UAP to offer back rubs to the client.
- B. Reassess the client and the level of pain.
- C. Encourage the client to focus on taking deep breaths.
- D. Tell the client the medication needs more time to work.
Correct Answer: B
Rationale: The nurse should reassess the client's pain level and determine if additional interventions are needed to manage the pain.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.