A nurse is caring for a client.
Click to specify if the client statements indicate understanding or no understanding.
"I will have to stop watching television while I eat."
"I won't be able to eat nuts anymore."
"My food will have to be the consistency of pudding."
"I can have cream soups on this diet."
"I will look up at the ceiling when I swallow."
"I shouldn't drink liquids while I have food in my mouth."
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"D"},"E":{"answers":"D"},"F":{"answers":"A"}}
"I will have to stop watching television while I eat." Understanding: Multitasking while eating can increase the risk of choking, so focusing on the meal is important.
"I won't be able to eat nuts anymore." Understanding: Nuts are not appropriate for a Level 3 dysphagia diet due to their texture, which can be a choking hazard.
"My food will have to be the consistency of pudding." Understanding: A Level 3 dysphagia diet involves foods with a pudding-like consistency to minimize choking risk.
"I can have cream soups on this diet." No Understanding: Cream soups are typically too thin for a Level 3 dysphagia diet, which requires thicker consistencies.
"I will look up at the ceiling when I swallow." No Understanding: The correct practice is to keep the head level or slightly tilted forward, not to look up at the ceiling.
"I shouldn't drink liquids while I have food in my mouth." Understanding: Drinking liquids while chewing food can increase the risk of aspiration or choking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
- Obtain intravenous access: Anticipated: Essential for administering medications, fluids, and potential emergency treatments.
- Thoracentesis: Non-essential: Typically used for pleural effusions, not primary treatment for pneumothorax; chest tube insertion is the main treatment.
- Pulmonary Function Tests (PFTs): Non-essential: Useful for diagnosing chronic respiratory conditions but not a primary intervention for pneumothorax.
- Prepare for insertion of a chest tube: Anticipated: A chest tube is often necessary to re-expand the lung and treat a significant pneumothorax.
- Obtain ABGs: Anticipated: Important for assessing the client’s oxygenation and acid-base balance due to respiratory distress.
- Computed tomography (CT) of the chest: Anticipated: CT can be used to diagnose the extent of the pneumothorax and guide treatment.
Correct Answer is B
Explanation
A. Securing the drain to the client's bed sheet is not an appropriate method for securing the JP drain; it should be secured to the client’s gown or clothing to avoid tension on the drain.
B. Expelling the air from the JP bulb after emptying to re-establish suction is necessary to ensure that the drain continues to function correctly by maintaining negative pressure.
C. Measuring the drainage every hour for the first 8 hr postoperative is more frequent than necessary; monitoring can be done every 4-8 hours depending on the protocol.
D. Removing the JP drain when the drainage has ceased, covering the opening with sterile gauze is incorrect; the drain should be removed per the surgeon’s orders, and the site should be covered with a sterile dressing.
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