A. This option is aimed at modifying the consistency of fluids to make them easier to swallow for someone with dysphagia. Thickened liquids are often recommended to prevent aspiration (when food or liquid enters the airway instead of the esophagus) in patients with swallowing difficulties.
B. Placing food on the unaffected side of the mouth, which would be the right side in the case of left-sided weakness, is recommended to aid in easier chewing and swallowing.
C. Temperature can affect how easily food can be swallowed and enjoyed by someone with dysphagia. Extremely hot or cold foods can be more challenging to swallow. However, this dose not address the risk of aspiration.
D. Tipping the head back during swallowing is not recommended because it can increase the risk of choking or aspiration. Instead of tilting the head back, clients with dysphagia should be instructed to maintain an upright position when eating and drinking.

A. A stage 3 pressure ulcer is characterized by full-thickness skin loss that may extend into the subcutaneous tissue layer but does not involve exposure of muscle, tendon, or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue as well.
B. This describes a stage 1 pressure ulcer. Stage 1 ulcers involve intact skin with non-blanchable redness, indicating potential damage to underlying tissue.

C. This describes a stage 2 pressure ulcer. Stage 2 ulcers involve partial-thickness loss of skin involving the epidermis and/or dermis, presenting as a shallow open ulcer or intact blister.
D. Accurately describes a stage 4 pressure ulcer.

A. Enteric-coated medications are designed to dissolve in the small intestine rather than the stomach. This is important for ileostomy patients because medications that dissolve in the stomach may be poorly absorbed or can cause irritation to the stoma or the small intestine.
B. It's recommended to empty the ostomy pouch when it's about one-third to half full to prevent leakage or discomfort.
C. How often the pouch system needs to be changed can vary depending on individual factors such as skin sensitivity, output consistency, and the type of pouch system used. Generally, changing the pouch system every 3-7 days is recommended.
D. High fiber foods can increase stool output and gas production, which can be challenging for individuals with an ileostomy. However, fiber is important for overall digestive health, so moderation rather than avoidance is typically recommended.

A. Gelatin is derived from collagen obtained from various animal body parts. It is commonly used in medications, including some capsules and intravenous (IV) preparations. It has no association with cardiac catheterization procedure.
B. This is because the contrast dye used during the procedure typically contains iodine, which can cause an allergic reaction in susceptible individuals.
C. Yeast allergies are reactions to proteins found in yeast, commonly used in baking and brewing and sometimes present in vaccines and medications. However, it has no association with cardiac catheterization procedure.
D. Egg allergies involve reactions to proteins found in eggs and can be present in vaccines, some medications, and some foods. However, it has no association with cardiac catheterization procedure.

(Volume to be infused (mL) × Drop factor (gtt/mL)) / Time (min).

For the given scenario, the calculation would be: (100 mL × 15 gtt/mL) / 60 min, which equals 25 gtt/min.

Therefore, the nurse should set the manual IV infusion to deliver 25 drops per minute.

A. Sour cream is a dairy product, providing protein. This option provides protein from the sour cream, which is suitable for a vegetarian who consumes dairy products.
B. Fruits and vegetables generally do not provide significant protein. While fruits and vegetables are nutritious, they do not provide sufficient protein for a meal, especially for someone who is vegetarian and needs adequate protein sources.
C. Cream cheese is a dairy product that provides protein. This option also provides protein from the cream cheese, which is suitable for a vegetarian who consumes dairy products.
D. Peanut butter is a plant-based protein source and enriched bread provides carbohydrates. Peanut butter is a good source of protein for vegetarians and is a suitable option for the adolescent client who does not like beans.

To administer a dose of 3 mg of dexamethasone when you have tablets of 1.5 mg, you would need to calculate the number of tablets that would equal the total required dose. In this case, since each tablet contains 1.5 mg, you would need two tablets to make up the 3 mg dose.

Therefore, the nurse should administer two tablets of dexamethasone

A. Body weight is one of the most reliable indicators of fluid status in a dialysis patient. Before and after each hemodialysis session, the nurse should weigh the client using the same scale under similar conditions (e.g., same clothing). The difference in weight reflects fluid loss during the dialysis treatment. This measurement helps guide adjustments in fluid management and dialysis prescriptions.
B. Abdominal girth can increase due to fluid accumulation in the abdomen (ascites) but is less specific for measuring fluid losses during dialysis. It may be more indicative of fluid retention over a longer period rather than immediate changes related to a single dialysis session.
C. Neck vein distention can be a sign of fluid overload but is not typically used to assess fluid losses during dialysis. It may be more relevant for assessing fluid status over time rather than immediate changes post- dialysis.
D. Blood pressure can fluctuate based on various factors, including fluid status. While blood pressure monitoring is essential in dialysis patients, it alone does not reliably reflect fluid losses during dialysis sessions.

A. This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B. Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues

or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C. A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D. Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.

A. Positioning the client's arm above heart level can result in a falsely low blood pressure reading. This is because gravity assists in the flow of blood downward, artificially reducing the pressure measured in the arteries. For accurate blood pressure measurement, the client's arm should be positioned at heart level or slightly below heart level.
B. If the blood pressure cuff is wrapped too loosely around the client's arm, it can lead to inaccurate readings. A loose cuff may allow leakage of air during inflation or may not provide sufficient compression to accurately detect the arterial pressure pulses.
C. Deflating the cuff too slowly can cause a falsely high diastolic pressure reading. When the cuff is deflated slowly, the pressure in the cuff remains close to the systolic pressure for a longer duration, leading to incorrect readings, especially in diastolic pressure.
Blood pressure can temporarily increase after meals due to digestion, particularly in clients with hypertension. Measuring blood pressure immediately after a meal may result in a higher reading that does not reflect the client's baseline blood pressure. However, this would typically lead to a higher reading rather than a lower one.