Nokea
The nursing instructor is supervising a nursing student feeding a client at risk for aspiration. Which action by the nursing student requires follow-up by the nursing instructor? Select all that apply.
- A. Instructs the client to tilt the head backward when drinking.
- B. Reminds the client to assume a chin-down position.
- C. Provides rest periods as needed during the meal.
- D. Positions the client upright for 30-60 minutes after a meal.
- E. Positions the head of the bed at a 45-degree angle during the meal.
Correct Answer: A
Rationale: Tilting the head backward increases aspiration risk. Chin-down position, rest periods, upright positioning, and 45-degree elevation are appropriate.
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The nurse is performing a home safety assessment for an older adult. Which of the following client statements would require follow-up by the nurse?
- A. I will have grab bars installed in the bathroom.
- B. I placed a non-skid mat in my shower.
- C. My furniture is arranged so I can hold onto something if I need it.
- D. I secured my electrical cords against the wall behind furniture.
Correct Answer: NONE
Rationale: All statements indicate proactive safety measures (grab bars, non-skid mat, furniture for support, and secured cords) that reduce fall risk, so no follow-up is needed.
The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child
- A. left lateral recumbent
- B. prone
- C. right lateral recumbent
- D. modified trendelenburg
Correct Answer: C
Rationale: Positioning the child on the right lateral recumbent side (operative ear up) post-myringotomy facilitates drainage from the left ear and prevents pressure on the surgical site. Left lateral recumbent or prone positions could obstruct drainage, and modified Trendelenburg is not indicated.
The nurse is visiting an older adult client with impaired vision. It would be necessary for the nurse to follow up if the client states which of the following? Select all that apply.
- A. I secured my throw rugs to the floor with tape.
- B. I switched to using an electric shaver instead of a razor.
- C. I usually sit in a recliner while I listen to the television.
- D. I use different shaped containers with lids to organize my medications.
- E. I use the upstairs bathroom instead of the one on the main floor.
Correct Answer: E
Rationale: Using an upstairs bathroom increases fall risk for a visually impaired client, requiring follow-up. Securing rugs, using an electric shaver, sitting in a recliner, and organizing medications are safe practices.
The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum
- A. potassium level
- B. calcium level
- C. sodium level
- D. glucose level
Correct Answer: B
Rationale: Total thyroidectomy can disrupt parathyroid function, leading to hypocalcemia due to decreased parathyroid hormone. Monitoring serum calcium levels is critical to detect and manage this complication. Potassium, sodium, and glucose levels are less directly affected by thyroidectomy.
The nurse is caring for assigned clients. Which of the following clients should the nurse identify is at the highest risk for falling?
- A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia
- B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide
- C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone
- D. 28-year-old admitted with bacteremia is receiving intravenous fluids via central line and is diaphoretic
Correct Answer: A
Rationale: The 88-year-old with dementia is at highest fall risk due to age and cognitive impairment.