A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

The client requires reinforcement of teaching about the purpose of his medications.

The client is unable to grasp eating utensils.

The client requests to perform ADLS later in the day.

The client tells the nurse he prefers a snack before bedtime.

Answer and Explanation

The Correct Answer is B

This issue indicates a potential difficulty with fine motor skills and may impact the client's ability to feed themselves independently.

It is important for the interprofessional team, including occupational therapy and/or physical therapy, to be aware of this issue and collaborate on appropriate interventions to improve the client's functional abilities and promote independence in activities of daily living (ADLs).

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Correct Answer is D

Explanation

a.This is not recommended. The central tip of the finger is more sensitive and has more nerve endings, which can cause more pain. The recommended site for blood glucose testing is the side of the fingertip, as it is less sensitive and provides an adequate blood sample.

b. While it is not necessary to wear sterile gloves for routine capillary blood glucose monitoring, it is important to ensure that the nurse's hands are clean. Wearing clean gloves helps maintain infection control practices.

c. After puncturing the selected site, the nurse should gently squeeze the finger to create a small drop of blood. The first drop of blood should be wiped away, and subsequent drops should be used for the glucose test. This ensures that the sample is fresh and not contaminated with tissue fluid.

d.Keeping the finger in a dependent position (hanging down) helps improve blood flow to the fingertip, making it easier to obtain a sufficient blood sample. This can help ensure an accurate glucose reading.

A. Remove the absorbent pads from underneath the client. B. Place a pillow under the client's head. C. Place the client in high-Fowler's position. D. Remove the client's dentures

Correct Answer is A

Explanation

The nurse should remove the absorbent pads from underneath the client, place the client in a supine position with arms at the sides, close the client's eyes, and replace the client's dentures.

A pillow may be placed under the client's head for cosmetic purposes, but this is not a necessary action. High-Fowler's position is not appropriate for a deceased client.

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A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

Explanation

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