A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client's ring?

Place the client's ring in the facility safe.

Place the ring in the bag with the client's clothing

Tape the ring securely to the client's finger

Agree to keep the ring for the client until after surgery.

Answer and Explanation

The Correct Answer is A

A. Placing the client's ring in the facility safe ensures that it is securely stored and prevents loss or misplacement, which is standard procedure for valuable personal items before surgery.
B. Placing the ring in the bag with the client’s clothing is not secure, as it increases the risk of loss or theft.
C. Taping the ring to the client’s finger is not ideal because jewelry should generally be removed before surgery to prevent complications such as swelling, circulation issues, or electrical burns from cautery equipment.
D. Keeping the ring for the client is inappropriate because staff should not personally hold onto a client’s valuables. Instead, valuables should be properly documented and stored per facility policy.

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Correct Answer is B

Explanation

A: Providing a 10-minute rest period prior to meals can be beneficial for some clients, but it is not specifically related to the prevention of aspiration in clients with dysphagia. Rest periods do not directly facilitate safer swallowing processes.

B: Elevating the head of the client's bed to 30° during mealtime is the correct technique for a client with dysphagia. This position helps prevent aspiration, which can occur if food or liquids enter the lungs instead of going down the esophagus. The semi-upright position aids in the proper alignment of the esophagus and reduces the risk of choking.

C: Withholding fluids until the end of the meal is not an appropriate technique for a client with dysphagia. Fluids are often needed to help swallow and clear the mouth of food particles. Additionally, providing fluids throughout the meal can help prevent dehydration.

D: Instructing the client to place her chin toward her chest when swallowing can help prevent aspiration in clients with dysphagia. However, this technique should be used in conjunction with other methods, such as the correct positioning of the bed, to ensure safety and effectiveness.

A. Implement a fall prevention plan. B. Review current literature regarding client falls. C. Notify staff of the increased fall rate. D. Identify clients who are at risk for falls.

Correct Answer is D

Explanation

A. Implementing a fall prevention plan is an important step but comes after identifying those at risk.
B. Reviewing current literature is important for understanding evidence-based practices, but it should come after identifying and assessing the specific risk factors in the facility.
C. Notifying staff of the increased fall rate is essential but doesn't directly address the root cause; it's more reactive than proactive.
D. Identifying clients who are at risk for falls is the initial step to intervene and prevent further incidents, forming the foundation for a targeted fall prevention plan.

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A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client's ring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia.Which of the following actions by the AP should the nurse identify as correct technique?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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