For a client at a high risk of aspiration, the nurse anticipates that there will be goals and interventions (taking action) related to safety observations during:

Feeding

Transferring

Bathing

Ambulation

Answer and Explanation

The Correct Answer is A

The correct answer is choice A, feeding. Aspiration is a serious risk for clients who have difficulty swallowing or have other conditions that increase the risk of food or liquid entering the airway. During feeding, the nurse should monitor the client closely for any signs of distress or difficulty swallowing. The nurse may need to modify the consistency or texture of the food or liquid or use assistive devices such as a straw or feeding tube to reduce the risk of aspiration. Additionally, the nurse may need to position the client upright and provide support as needed during feeding. While safety observations are important during all activities, feeding is the most critical activity for clients at high risk of aspiration.

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Correct Answer is C

Explanation

The correct answer is choice C. Cyanosis. Cyanosis is a medical emergency and requires immediate action by the nurse. It indicates that the client is not receiving adequate oxygenation and can lead to respiratory failure if not addressed promptly. Pallor (Option A) and erythema (Option D) are concerning but are not immediate priorities compared to cyanosis. Jaundice (Option B) may indicate liver dysfunction but is not an immediate priority unless it is associated with other symptoms such as severe abdominal pain or altered mental status.

A. Stool is hard and has a consistency of small marbles. B. Bowel sounds are hyperactive in all four quadrants. C. Client reports they have not had a bowel movement for the past 4 days. D. Client reports urgency when needing to have a bowel movement. E. Client states they have to strain hard when having a bowel movement.

Correct Answer is ["A","C","E"]

Explanation

The correct answer is choices A, C, and E.

Stool is hard and has a consistency of small marbles is a sign of constipation.
Bowel sounds that are hyperactive in all four quadrants are an indication of diarrhea rather than constipation.
Client reports they have not had a bowel movement for the past 4 days supports the diagnosis of constipation.
Client reports urgency when needing to have a bowel movement is more indicative of diarrhea than constipation.
Client states they have to strain hard when having a bowel movement is a sign of constipation.

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For a client at a high risk of aspiration, the nurse anticipates that there will be goals and interventions (taking action) related to safety observations during:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a head to toe assessment on a client. Which of the following assessment findings would the nurse recognize as requiring an immediate action and would be the first priority when addressing a patient health problem?

Correct Answer is C

Explanation

The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem. Which assessment cues would support constipation? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A nurse asks a client the current level of pain using a scale of 0 to 10 after administering pain medications 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?

A nurse is teaching a preoperative patient how to use an incentive spirometer. Which instruction should be included in the education to the patient?

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for further education and reinforcement of the principles of asepsis?

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is characteristic of the denial stage?