A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make?

Ensure that all area rugs are rubber-backed.

Wear slippers with cloth soles.

Place a towel on the floor outside of the shower.

Place a handrail in the entryway of the house.

Answer and Explanation

The Correct Answer is A

A) Ensure that all area rugs are rubber-backed: Rubber-backed rugs help prevent slips and falls by keeping the rugs securely in place on the floor. This is particularly important for someone recovering from knee surgery to avoid additional injury and ensure a safe home environment.

B) Wear slippers with cloth soles: Slippers with cloth soles can be slippery and increase the risk of falls. It is safer to wear slippers with non-slip soles to provide better traction and stability.

C) Place a towel on the floor outside of the shower: Placing a towel on the floor can create a slipping hazard. Instead, using a non-slip bath mat outside the shower is recommended to prevent falls.

D) Place a handrail in the entryway of the house: While placing a handrail in the entryway can be beneficial, it is not as immediately critical as ensuring that area rugs are rubber-backed to prevent falls throughout the home. Handrails are more commonly recommended for stairs and bathrooms.

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Correct Answer is A

Explanation

A. A history of gastroesophageal reflux disease: This factor places the client at a higher risk for aspiration. Patients with gastroesophageal reflux disease (GERD) may experience backflow of stomach contents, which can lead to aspiration, especially when receiving enteral feedings.

B. A residual of 65 mL, 1 hr postprandial: While monitoring residual volumes is important to assess tolerance to feeding, a residual of 65 mL alone does not inherently indicate a high risk for aspiration. It may suggest that the feeding rate needs adjustment but isn't a direct risk factor.

C. Sitting in high-Fowler's position during the feeding: This position is actually protective against aspiration, as it promotes better gastric emptying and reduces the likelihood of reflux.

D. Receiving a high-osmolarity formula: While high-osmolarity formulas can sometimes lead to gastrointestinal discomfort or diarrhea, they do not directly increase the risk of aspiration. Proper management of feeding administration is key.

A. Tinnitus B. Drooling C. Fever D. Steatorrhea

Correct Answer is C

Explanation

A) Tinnitus: This is not typically associated with pneumonia. Tinnitus refers to ringing in the ears and is more related to auditory issues rather than respiratory infections.

B) Drooling: While drooling may occur in some cases of severe throat infections or in children with difficulty swallowing, it is not a classic sign of pneumonia.

C) Fever: This is the correct answer. Fever is a common manifestation of bacterial pneumonia in children, indicating an immune response to infection. It often accompanies other symptoms like cough and difficulty breathing.

D) Steatorrhea: This refers to fatty stools, which are more associated with malabsorption syndromes or pancreatic issues, not pneumonia. It is not an expected manifestation of bacterial pneumonia.

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A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make?

Nursing Test Bank

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