A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

A client who has Guillain-Barré syndrome

A client who has systemic sclerosis

A client who has amyotrophic lateral sclerosis (ALS)

A client who has a lumbosacral spinal tumor

Answer and Explanation

The Correct Answer is D

Choice A reason:

A client who has Guillain-Barré syndrome: Guillain-Barré syndrome (GBS) can cause significant muscle weakness and paralysis, including the muscles involved in swallowing. Clients with GBS are at high risk for aspiration and may require specialized feeding techniques or assistance from a nurse rather than an AP.

Choice B reason:

A client who has systemic sclerosis: Systemic sclerosis, also known as scleroderma, can affect the esophagus and cause difficulty swallowing. These clients may need careful monitoring and assistance with meals to prevent choking and ensure adequate nutrition.

Choice C reason:

A client who has amyotrophic lateral sclerosis (ALS): ALS affects the motor neurons and can lead to progressive muscle weakness, including the muscles involved in swallowing. Clients with ALS often require specialized feeding techniques and close monitoring during meals to prevent aspiration.

Choice D reason:

A client who has a lumbosacral spinal tumor: A lumbosacral spinal tumor primarily affects the lower back and may cause pain or mobility issues, but it does not typically impair swallowing. Therefore, this client is the most appropriate for the AP to assist with meals, as they are less likely to have complications related to eating.

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Correct Answer is B

Explanation

Choice A reason:

Inserting a nasogastric tube is not the first-line intervention for postoperative nausea and vomiting (PONV). This invasive procedure is typically reserved for severe cases where other interventions have failed.

Choice B reason:

Administering an antiemetic is the appropriate action. Antiemetics help control nausea and vomiting, which are common side effects of opioids like morphine. This intervention can provide immediate relief and improve the client’s comfort.

Choice C reason:

Auscultating bowel sounds is important for assessing gastrointestinal function, but it does not directly address the immediate symptom of nausea and vomiting. This assessment can be part of the overall evaluation but is not the primary intervention.

Choice D reason:

Encouraging the client to ambulate is beneficial for overall recovery and can help reduce the risk of complications such as deep vein thrombosis. However, it does not directly address the immediate issue of nausea and vomiting.

A. The medication will reduce inflammation. B. The medication will decrease coughing episodes. C. The medication will prevent wheezing. D. The medication will open the airway. E. The medication will stimulate the flow of mucus.

Correct Answer is ["C","D"]

Explanation

Choice A reason:

Albuterol is primarily a bronchodilator and does not significantly reduce inflammation. Anti-inflammatory medications, such as corticosteroids, are typically used to address inflammation in the airways.

Choice B reason:

While albuterol can help reduce coughing episodes by opening the airways and making breathing easier, it is not its primary function. Coughing can be a symptom of bronchospasm, which albuterol helps to relieve.

Choice C reason:

Albuterol is effective in preventing wheezing by relaxing the muscles around the airways, which helps to open them up and allow more air to flow through. This action helps to alleviate wheezing, a common symptom of asthma and other respiratory conditions.

Choice D reason:

The primary function of albuterol is to open the airways. It is a bronchodilator that works by relaxing the smooth muscles around the airways, allowing them to widen and making it easier to breathe.

Choice E reason:

Albuterol does not stimulate the flow of mucus. Its main action is to relax the airway muscles and improve airflow. Mucus production is typically managed by other medications or treatments.

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A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply)

Correct Answer is ["C","D"]

Explanation

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