A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but the care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Protective Supine

Semi-Fowlers

Low-Fowlers

Fowlers

Answer and Explanation

The Correct Answer is B

Choice A rationale: Protective supine positioning is not ideal for managing dysphagia or facilitating swallowing.
Choice B rationale: Semi-Fowlers positioning, with the head of the bed elevated at a 30 to 45-degree angle, is often recommended for clients with dysphagia. This position helps prevent aspiration during eating and promotes effective swallowing.
Choice C rationale: Low-Fowlers and Fowlers positions may not be as effective in preventing aspiration during eating as the Semi-Fowlers position.
Choice D rationale: Fowlers positioning alone may not be sufficient for managing dysphagia; Semi-Fowlers is a more specific recommendation.

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Correct Answer is C

Explanation

Choice A rationale: Leaning the client toward the wall may not provide sufficient support and could lead to a fall.
Choice B rationale: Assuming a narrow base of support does not provide adequate stability when a client is falling.
Choice C rationale: Lowering the client to the floor is a safety measure to prevent injury during a fall. It reduces the distance of the fall and minimizes the risk of injury.
Choice D rationale: Providing support by holding the client's arm may not be sufficient to prevent a fall. Lowering the client to the floor is a safer option.

A. Stage I Pressure Ulcer B. Stage II Pressure Ulcer C. Stage IV Pressure Ulcer D. Stage III Pressure Ulcer

Correct Answer is B

Explanation

Choice A rationale: Stage I pressure ulcers consist of non-blanching erythema with an intact epidermis unlike in the above picture.
Choice B rationale: This is correct since Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers as shown in the image above.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.

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A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but the care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

Correct Answer is B

Explanation

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

A nurse is preparing to complete a digital removal of a fecal impaction. What statement indicates the nurse has an appropriate understanding of this procedure? (Select All that Apply.)

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?

What are the functions of the skin? (Select All that Apply.)

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?