A nurse is providing discharge teaching to a client who has generalized myasthenia gravis. Which of the following information should the nurse include?

Encourage the client to eat a large meal in the evening.

Recommend the client eat within 45 min of taking cholinesterase-inhibitor medication.

Recommend the client extend their neck to facilitate swallowing.

Encourage the client to contact an occupational therapist to learn techniques of avoiding aspiration.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Encourage the client to eat a large meal in the evening: Clients with myasthenia gravis experience progressive muscle weakness, especially later in the day. Eating large evening meals increases the risk of fatigue and aspiration because muscle strength is reduced after activity.

B. Recommend the client eat within 45 min of taking cholinesterase-inhibitor medication: Cholinesterase inhibitors, such as pyridostigmine, enhance neuromuscular transmission and improve muscle strength. Eating within 45 minutes of taking the medication ensures optimal swallowing ability and reduces the risk of aspiration by aligning mealtime with peak effect.

C. Recommend the client extend their neck to facilitate swallowing: Extending the neck actually increases the risk of aspiration by opening the airway. Clients should be instructed to flex the neck slightly forward while swallowing to close the airway and promote safe swallowing mechanics.

D. Encourage the client to contact an occupational therapist to learn techniques of avoiding aspiration: While an occupational therapist can provide helpful adaptive techniques, primary aspiration prevention teaching should come directly from the nurse and speech-language pathologist.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. Skin warm and dry: Warm, dry skin indicates adequate circulation and fluid balance. In fluid overload, the skin is often cool and moist due to peripheral vasodilation and increased interstitial fluid. Therefore, this finding is not consistent with overhydration.

B. Respiratory rate 30/min: Tachypnea is a key indicator of fluid overload because excess fluid can accumulate in the lungs, leading to pulmonary congestion and decreased gas exchange. The body compensates by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide.

C. Heart rate 60/min: A normal heart rate suggests stable cardiovascular status. Fluid overload typically causes tachycardia as the heart works harder to manage increased circulatory volume, not a normal or bradycardic rate.

D. Tenting skin turgor: Tenting indicates dehydration, not fluid overload. In overhydration, the skin is usually taut and edematous due to excess interstitial fluid accumulation rather than loss of elasticity.

A. A client who is receiving a blood transfusion and reports low-back pain B. A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x105/uL (4.2 to 5.4 x106/uL) C. A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing D. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag

Correct Answer is A

Explanation

Rationale:
A. A client who is receiving a blood transfusion and reports low-back pain: Low-back pain during a blood transfusion indicates a possible acute hemolytic reaction caused by ABO incompatibility. This is a life-threatening emergency that requires immediate discontinuation of the transfusion and notifying the provider to prevent renal failure and shock.

B. A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x10⁶/µL (4.2–5.4 x10⁶/µL): Although the RBC count is slightly low, this finding is not immediately life-threatening. The provider should be informed, but the client does not require urgent intervention.

C. A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing: Small clots are expected during the first 24 to 36 hours post-TURP due to residual bleeding from the surgical site.

D. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag: Small amounts of bloody mucus are normal during the early postoperative phase as the bowel mucosa heals.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is providing discharge teaching to a client who has generalized myasthenia gravis. Which of the following information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit is receiving reports for four clients. Which of the following clients should the nurse assess first?

Correct Answer is A

Explanation

A nurse in an emergency department is caring for a client who has manifestations of an ischemic stroke that began 2 hr ago. Which of the following actions should the nurse take?

A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

A nurse in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?

A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?

A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

A community health nurse is performing a home health admissions assessment with a client. The client reports being unable to obtain their prescriptions. Which of the following actions should the nurse take first?

A nurse is instructing a client about food safety during pregnancy. Which of the following information should the nurse include?

A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." Which of the following responses by the nurse is appropriate? (Select all that apply.)