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1. A client has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?
- A. Providing a straw for consumption of liquids
- B. Encouraging larger bites
- C. Placing the client in semi-Fowler's position during meals
- D. Instructing the client to tilt head forward when swallowing
Correct answer: C
Rationale: Placing the client in semi-Fowler's position during meals is the correct intervention for a client with acute dysphagia. This position helps prevent aspiration by facilitating swallowing. Providing a straw for consumption of liquids (Choice A) can increase the risk of aspiration and is not recommended for clients with dysphagia. Encouraging larger bites (Choice B) can also increase the risk of choking and aspiration. Instructing the client to tilt the head forward when swallowing (Choice D) is not the recommended technique for managing dysphagia as it does not address the underlying issue effectively.
2. A client with anorexia undergoing radiation therapy is being taught by a nurse. Which instruction should the nurse include in the teaching?
- A. Limit high-calorie supplements to between meals
- B. Avoid overeating during your 'good' days
- C. Eat hot foods instead of cold foods
- D. Consume nutrient-dense foods first
Correct answer: D
Rationale: The correct instruction for a client with anorexia undergoing radiation therapy is to consume nutrient-dense foods first. This ensures that the client receives the necessary calories and nutrients. Option A is incorrect because high-calorie supplements should not be limited but rather incorporated wisely into the diet. Option B is incorrect as overeating is not recommended regardless of the type of day. Option C is incorrect as there is no specific preference for hot foods over cold foods in managing anorexia during radiation therapy.
3. The preferred route of administration of medication in the most acute care situations is which of the following routes?
- A. Intravenous C. Subcutaneous
- B. Epidural D. Intramuscular
- C.
- D.
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
4. You are doing bed bath to the client when suddenly, The nursing assistant rushed to the room and tell you that the client from the other room was in Pain. The best intervention in such case is:
- A. Raise the side rails, cover the client and put the call bell within reach and then attend to the client in pain to give the
- B. Tell the nursing assistant to give the pain medication to the client complaining of pain
- C. Tell the nursing assistant to go the client’s room and tell the client to wait
- D. Finish the bed bath quickly then rush to the client in Pain
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
5. A client is being taught about foods to include in a low-fiber diet. Which statement indicates the client understands the teaching?
- A. "A fresh pear would be a good snack option."?
- B. "I can prepare refried beans for supper."?
- C. "Bran cereal would be a good breakfast choice."?
- D. "I should choose white rice as a side dish."?
Correct answer: D
Rationale: The correct answer is "I should choose white rice as a side dish." In a low-fiber diet, foods that are low in fiber are recommended to reduce gastrointestinal irritation. White rice is a low-fiber option suitable for this diet. Choices A, B, and C are high-fiber options and not suitable for a low-fiber diet. A fresh pear, refried beans, and bran cereal are all high in fiber, which should be avoided in a low-fiber diet.
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