Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

Solid with red streaks.

Formed but soft.

Brown liquid.

Tarry appearance.

Multiple hard pellets.

Answer and Explanation

Correct Answer : A,C,D,E

A. Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation.
B. Formed but soft stool is a normal finding and does not require follow-up.
C. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment.
D. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up.
E. Multiple hard pellets may indicate constipation or dehydration and should be addressed.

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Correct Answer is ["16"]

Explanation

The healthcare provider prescribed 800,000 units of penicillin and the vial available is labeled 50,000 units/mL.

To calculate the number of mL to administer, you need to divide the total number of units prescribed (800,000) by the number of units per mL (50,000).

This gives you a result of 16 mL.

Therefore, the nurse should administer 16 mL of penicillin to the patient.

A. Places food on the unaffected side of the mouth. B. Raises the head of the bed to 80 degrees. C. Positions the head with the chin tilted slightly downward. D. Allows 30 minutes of rest before feeding.

Correct Answer is B

Explanation

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

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Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["16"]

Explanation

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is B

Explanation

Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse is inappropriate?

The nurse is using guided imagery with a client who is experiencing chronic pain. What should the nurse direct the client's attention on during the session?

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The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions. Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?