For a client at a high risk of aspiration, the nurse anticipates that there will be goals and interventions (taking action) related to safety observations during:
Feeding
Transferring
Bathing
Ambulation
The Correct Answer is A
The correct answer is choice A, feeding. Aspiration is a serious risk for clients who have difficulty swallowing or have other conditions that increase the risk of food or liquid entering the airway. During feeding, the nurse should monitor the client closely for any signs of distress or difficulty swallowing. The nurse may need to modify the consistency or texture of the food or liquid or use assistive devices such as a straw or feeding tube to reduce the risk of aspiration. Additionally, the nurse may need to position the client upright and provide support as needed during feeding. While safety observations are important during all activities, feeding is the most critical activity for clients at high risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["333"]
Explanation
To calculate the infusion rate, we need to divide the total volume to be infused by the total time of infusion and then multiply by 60 to convert to mL/h:
1000 mL ÷ 3 hours = 333.33 mL/h
Rounding to the nearest whole number, the IV pump should be programmed for 333 mL/h.
Correct Answer is D
Explanation
Upon discovering that the client's abdominal wound has been eviscerated, the nurse should immediately cover the wound area with sterile gauze moistened with sterile 0.9% normal saline. This will help to protect the exposed organs and prevent them from becoming dry or exposed to contaminants. Pouring hydrogen peroxide into the abdominal cavity can cause further damage to the exposed organs and is not recommended. Similarly, normal saline should be gently poured on the area to moisten it, but organs should not be placed back into the cavity as this can cause further injury. Attempting to close the wound area with reinforced adhesive skin closures is also not appropriate as the wound needs to be assessed and repaired by a healthcare provider. The nurse should call the healthcare provider and provide ongoing assessment and support to the client while waiting for further interventions.
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