Nokea
Which of the following actions should the nurse include in the plan of care?
- A. Give cromolyn nebulized solution every 8 hr
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Apply a warm compress to the operative site once daily
- D. Offer small amounts of clear liquids 6 hr following surgery.
Correct Answer: B
Rationale: The correct answer is B because administering analgesics on a scheduled basis for the first 24 hours post-surgery helps manage pain effectively. Pain management is crucial for patient comfort and promotes early mobilization. Choice A is incorrect because cromolyn nebulized solution is not typically used post-operatively. Choice C is incorrect as applying a warm compress once daily may not provide adequate pain relief. Choice D is incorrect as clear liquids are usually started slowly to prevent nausea and vomiting, not 6 hours post-surgery.
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A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Instruct the client to lift her chin when swallowing
- B. Talk with the client during her feeding.
- C. Sit at or below the client's eye level during feedings
- D. Discourage the client from coughing during feedings
Correct Answer: C
Rationale: The correct answer is C: Sit at or below the client's eye level during feedings. This is important for clients with dysphagia as it helps facilitate safe swallowing by promoting proper alignment of the head and neck. Sitting at or below the client's eye level reduces the risk of aspiration and choking during feeding. This position also allows the nurse to closely monitor the client for signs of difficulty swallowing.
Choice A is incorrect because instructing the client to lift her chin when swallowing can actually increase the risk of aspiration in individuals with dysphagia. Choice B is incorrect as talking with the client during feeding may distract them and increase the risk of swallowing difficulties. Choice D is incorrect because coughing is a protective mechanism that helps clear the airway, so discouraging coughing during feedings is not recommended for clients with dysphagia.
After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?
- A. Flush the catheter with saline
- B. Retract the stylet
- C. Advance the catheter into the vein
- D. Release the tourniquet
Correct Answer: C
Rationale: The correct answer is C: Advance the catheter into the vein. After confirming blood return in the flashback chamber, advancing the catheter ensures proper placement within the vein for medication delivery. Retracting the stylet (B) prematurely can displace the catheter. Flushing with saline (A) before confirming placement is risky. Releasing the tourniquet (D) is done after securing catheter placement.
Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Frequent nosebleeds
- C. Upper extremity hypotension
- D. Increased intracranial pressure
Correct Answer: A
Rationale: Coarctation causes weak or absent femoral pulses.
Which of the following actions should the nurse expect from the leader during the session?
- A. The leader allows the group to discuss whatever they would like to regarding their medications
- B. The leader encourages group members to remain silent until questions are called for
- C. The leader has group members vote on what they would like to learn about during the session.
- D. The leader lectures about medication adverse effects to the group members.
Correct Answer: A
Rationale: The correct answer is A. The leader should allow the group to discuss whatever they would like regarding their medications to encourage active participation and engagement. This approach promotes a patient-centered discussion, empowers group members to share their experiences, concerns, and questions, and fosters a supportive and collaborative learning environment. This helps to address individual needs and promote a deeper understanding of medication management.
Choice B is incorrect because it inhibits open communication and stifles group participation. Choice C is incorrect as it may not address the specific needs of the group and may limit the discussion to only popular topics. Choice D is incorrect as it is a passive approach and does not promote active engagement or address individual concerns.
The nurse observes blood on the child's dressing.Which of the following actions should the nurse take?
- A. Apply intermittent pressure 2.5 cm(1 in) below the percutaneous skin site
- B. Apply continuous pressure 2.5 cm(1 in) above the percutaneous skin site
- C. Apply continuous pressure 2.5 cm(1 in) below the percutaneous skin site.
- D. Apply intermittent pressure 2.5 cm(1 in) above the percutaneous skin site
Correct Answer: B
Rationale: Continuous pressure above the site controls bleeding effectively.