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

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is choice D. The description of full-thickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer indicates a pressure ulcer that is categorized as stage IV. In this stage, the ulcer is characterized by fullthickness tissue loss, exposing muscle, bone, or tendons. Stage I (choice A) pressure injuries involve non-blanchable erythema of intact skin. Stage II (choice B) pressure injuries involve partial-thickness skin loss, which can involve the epidermis, dermis, or both. Stage III (choice C) pressure injuries involve fullthickness tissue loss, but not bone, tendon, or muscle. Therefore, based on the description provided, the pressure ulcer is categorized as stage IV.

A. Vitamins B. Lipids C. Protein D. Carbohydrates

Correct Answer is C

Explanation

The correct answer is choice C. Protein is most important for wound healing. After abdominal surgery, the client requires adequate protein to promote wound healing and tissue repair. Protein is essential for collagen synthesis, a protein that is responsible for the tensile strength of the wound. The recommended daily allowance for protein for an adult is 0.8 g/kg of body weight. Foods high in protein include meat, fish, poultry, dairy products, beans, and nuts.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?

Correct Answer is D

Explanation

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

Correct Answer is C

Explanation

The nurse is inserting an indwelling urinary catheter for a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

The nurse is caring for a client with moderate vision loss. Which intervention would be most appropriate for this client?

A nurse is implementing interventions to prevent a patient from developing Deep Vein Thrombosis (DVT) in the legs by applying a pneumatic or sequential compression device (SCD's). Which explanation would the nurse give the patient in regards to how this device works?

Which technique should the nurse use to assess the pupillary reaction on a client?

A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status. Which of the following guidelines should the nurse include? Select all that apply.

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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: