for a client requiring total oral care it is important for the nurse to

NCLEX-PN

Next Generation Nclex Questions Overview 3.0 ATI Quizlet

1. For a client requiring total oral care, it is important for the nurse to:

A. assemble all equipment, assist the client to a semi-Fowler's position, and place a towel on his chest.
B. place the client in Fowler's position, prepare the equipment, and instruct the client what to do.
C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
D. use gloves and clean the client's mouth, including the tongue.

Correct answer: C

Rationale: To provide total oral care to a client, the nurse should first assemble all necessary equipment. Placing the client in a side-lying position helps fluids to easily flow out or pool in the side of the mouth for suctioning, thus preventing aspiration. Additionally, placing a towel under the client's chin and a curved basin against the chin helps to maintain cleanliness during the procedure. Choice A is incorrect because the client should be placed in a side-lying position, not a semi-Fowler's position which is used for respiratory issues. Choice B is incorrect as it does not emphasize the importance of proper positioning for effective oral care. Choice D is incorrect as it oversimplifies the procedure by focusing only on cleaning the mouth without considering the importance of positioning and preparation.

2. Which of these would be an appropriate meal for a client with Celiac disease?

A. egg noodles with cream sauce and broccoli, oat cookie, almond milk
B. turkey sandwich with rye bread, carrots
C. chicken and rice, apple, and tapioca pudding
D. granola and dried apricots with cow's milk

Correct answer: C

Rationale: For individuals with Celiac disease, it's crucial to avoid gluten-containing foods. Choice C, which includes chicken, rice, apple, and tapioca pudding, is the most suitable option as all these foods are naturally gluten-free. Rice, fruits, vegetables, meat, dairy, and tapioca are all safe gluten-free options. Oats can be gluten-free if specially labeled, but many are processed on shared equipment with wheat. Granola often contains oats that may have been exposed to gluten. Dried and prepackaged fruits may contain gluten additives. Rye is a wheat derivative, and cream sauces usually contain flour as a base, making choices A and B inappropriate for individuals with Celiac disease.

3. A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation?

A. Ignoring the situation
B. Documenting the problem in the nursing assistant's personnel file
C. Asking other staff members to cover for the nursing assistant
D. Meeting with the nursing assistant to discuss the behavior and initiate problem-solving measures

Correct answer: D

Rationale: Taking extended lunch breaks is an unacceptable behavior, especially when it affects client care. The appropriate way for the nurse to deal with this situation is to meet with the nursing assistant to discuss the behavior and initiate problem-solving measures. This direct approach allows for open communication and the opportunity to address the issue effectively. Ignoring the situation (Choice A), asking other staff members to cover (Choice C), or documenting the problem in the nursing assistant's personnel file (Choice B) are not effective solutions. Ignoring the behavior does not address the issue, asking others to cover may not solve the problem at its root, and documenting the problem should come after attempting to resolve the issue through communication and problem-solving first.

4. A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up?

A. A client is performing their own colostomy irrigations.
B. A client with a central venous catheter has a temperature of 100.6�F.
C. A client who has just undergone surgery has a urine output of more than 30 mL/hr.
D. A client with a new diagnosis of diabetes mellitus is self-administering insulin.

Correct answer: B

Rationale: A case manager is a healthcare professional responsible for coordinating a client's care from admission through and after discharge. They evaluate and update the plan of care as needed, monitoring for unexpected outcomes and providing follow-up. A temperature of 100.6�F in a client with a central venous catheter is an unexpected outcome that requires follow-up due to the potential indication of an infection. Choices A, C, and D describe expected outcomes and appropriate self-care management. The client self-irrigating their colostomy, a post-surgical client having adequate urine output, and a newly diagnosed diabetic self-administering insulin are all positive indicators of self-care and expected outcomes, not requiring immediate follow-up.

5. What should be included in the assessment of a client with a cast?

A. capillary refill, warm toes, no discomfort.
B. posterior tibial pulses, warm toes.
C. moist skin essential, pain threshold.
D. discomfort of the metacarpals.

Correct answer: A

Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client. Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.