30. The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink throug... [Show More] h a straw. Which intervention should the nurse implement?
a. Assess the client’s oral cavity for ulcerations. b. Monitor the client when using a straw for liquids.
c. Teach coughing and deep breathing exercises.
d. Request thick nectar liquids for the client.
31. A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement?
a. Bring a bedside commode to the client. b. Stand on the client’s right side as he walks.
c. Walk directly behind the client to prevent a fall.
d. Give the client a cane to hold in his right hand.
32. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement?
a. Ask family members to remain with the client in the evening from 1700 to 2100 p.m. b. Ensure that the client is assigned to a room close to the nurses’ station.
c. Postpone administration of nighttime medications until after 2300 p.m.
d. Administer a prescribed PRN benzodiazepine at the onset of a confused state.
33. The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client’s plan of care?
a. Ensure adequate IV and oral fluid intake.
b. Provide ice packs to major joint areas.
c. Space analgesics to prevent addiction to narcotics.
d. Re-enforce the importance of nutritional balance.
34. The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of preeclampsia and should be reported to the healthcare provider? (select all that apply.)
a. Blurred vision b. Headache.
c. Lack of appetite.
d. Urinary frequency.
e. Chills and fever. f. Swollen hands.
35. A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement?
a. Suggest the nurse use a 20-gauge needle. b. Direct the nurse to change the IV tubing.
c. Instruct the nurse to remove the needle.
d. Prompt the nurse to apply povidone to the site.
36. A client with syndrome of inappropriate antidiuretic hormone secretion (SIDH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury?
a. Initiate seizure precautions.
b. Assess neurological status every 8 hours.
c. Limit oral water intake.
d. Administer a hypertonic IV fluids as prescribed. [Show Less]