The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement?

Assist the client to lie down and turn to the side.

Recommend the use of supplemental liquid feedings.

Demonstrate use of a tucked-chin position while eating.

Encourage the use of assistive feeding devices.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assisting the client to lie down may increase the risk of aspiration.

Choice B reason: Supplemental liquid feedings may be considered but do not address the immediate issue.

Choice C reason: Demonstrating the tucked-chin position can help reduce the risk of aspiration by ensuring the airway is protected during swallowing.

Choice D reason: Assistive feeding devices may help but do not address the immediate issue of frequent coughing during meals.

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Correct Answer is A

Explanation

Choice A reason: Administering cefazolin, an antibiotic, is a priority to prevent or treat potential infections in the immediate postoperative period.

Choice B reason: Completing a CBC in the morning is important for ongoing assessment but is not an immediate priority.

Choice C reason: Advancing the diet as tolerated is important but can be done after ensuring infection prevention.

Choice D reason: Straight catheterization is necessary if the client is unable to void but is not the immediate priority compared to preventing infection.

A. Report the client's jaw pain to the healthcare provider. B. Advise the client to gargle with warm salt water twice daily. C. Determine how the client is administering the medication. D. Confirm that this is a common symptom of osteoporosis.

Correct Answer is A

Explanation

Choice A reason: Reporting the client's jaw pain to the healthcare provider is essential because jaw pain can be a symptom of osteonecrosis of the jaw, a rare but serious side effect of bisphosphonate therapy.

Choice B reason: Advising the client to gargle with warm salt water may provide temporary relief, but it does not address the underlying issue of potential osteonecrosis.

Choice C reason: Determining how the client is administering the medication is important for proper use but does not address the immediate concern of jaw pain.

Choice D reason: Confirming that this is a common symptom of osteoporosis is incorrect. Jaw pain is not a common symptom of osteoporosis and requires further evaluation.

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The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Correct Answer is A

Explanation

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is A

Explanation

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