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What should the nurse include in the care plan for a client with dysphagia?
- A. Offer thin liquids.
- B. Use a chin-tuck maneuver.
- C. Provide a low-fiber diet.
- D. Encourage rapid eating.
Correct Answer: B
Rationale: The chin-tuck maneuver reduces aspiration risk in clients with dysphagia.
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A client is to receive enoxaparin (Lovenox) 6 hours before the scheduled time of her laparoscopic vaginal assisted hysterectomy. Which of the following effects does the nurse recognize as an intended therapeutic action of the enoxaparin?
- A. Increase in red blood cell production.
- B. Reduction of postoperative thrombi.
- C. Decrease in postoperative bleeding.
- D. Promotion of tissue healing.
Correct Answer: B
Rationale: Enoxaparin is an anticoagulant that prevents postoperative thrombi by inhibiting clot formation, reducing the risk of deep vein thrombosis or pulmonary embolism.
A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client’s urinalysis results (see chart). The nurse should:
- A. Encourage the client to increase fl uid intake.
- B. Withhold the next dose of antihypertensive medication.
- C. Restrict the client’s sodium intake.
- D. Encourage the client to eat at least half of a banana per day
Correct Answer: A
Rationale: The client’s urine specifi c gravity is elevated. Specific gravity is a refl ection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.
Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects?
- A. Retinopathy.
- B. Constipation.
- C. Flulike symptoms.
- D. Hypoglycemia.
Correct Answer: C
Rationale: Interferon alfa-2b commonly causes flulike symptoms (C), such summer fever, chills, and fatigue. Retinopathy (A), constipation (B), and hypoglycemia (D) are not typical adverse effects.
A client has an emergency embolectomy for an embolus in the femoral artery. After the client returns from the recovery room, in what order, from first to last, should the nurse provide care?
- A. Administer pain medication
- B. Draw blood for laboratory studies
- C. Regulate the I.V. infusion
- D. Monitor the pulses
- E. Inspect the dressing
Correct Answer: D,C,A,B,E
Rationale: Order: 1) Monitor pulses (ensure arterial patency post-embolectomy); 2) Regulate I.V. infusion (maintain hydration/perfusion); 3) Administer pain medication (manage comfort); 4) Draw blood for labs (monitor coagulation); 5) Inspect dressing (check for bleeding/infection).
A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for:
- A. Footdrop.
- B. Knee swelling and pain.
- C. Tingling in the arm.
- D. Absence of the Achilles reflex.
Correct Answer: C
Rationale: Thoracoscopy positioning (lateral decubitus) can compress nerves in the arm, causing tingling due to brachial plexus injury. Footdrop or Achilles reflex issues are unrelated to this position.