A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first?

Place the client's valuables in the facility's safe.

Observe the client's level of mobility.

Administer prescribed medications.

Electronically enter the prescriptions from the provider.

Answer and Explanation

The Correct Answer is B

A. Place the client's valuables in the facility's safe - While securing the client's valuables is important, it is not the priority upon admission.

B. Observe the client's level of mobility - This is the priority as it allows the nurse to assess the client's immediate physical condition and risk of falls or other mobility-related issues.

C. Administer prescribed medications - Medication administration can wait until the client's initial assessment, including mobility, has been completed.

D. Electronically enter the prescriptions from the provider - Entering prescriptions can be done after the initial assessment and immediate needs of the client have been addressed.

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Correct Answer is C

Explanation

A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.

B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.

C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.

D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.

A. A B. B C. C

Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}

Explanation

A. To best hear the closing of the aortic heart valve, the nurse should place the diaphragm of the stethoscope at the second intercostal space, right sternal border. This is also known as the aortic area.
B. This is the tricuspid region, and defects with the tricuspid valve will be best heard in this area.
C. This is the mitral region and murmurs due to defects in the mitral valve will be appreciated here

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A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?

Correct Answer is C

Explanation

A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}

Explanation

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