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: "The doctors must have made a mistake." KüblerRoss defines five stages of psychosocial responses to dying and death: denial, anger, bargaining, depression, and acceptance. Denial is the first stage, characterized by a refusal to accept the reality of the situation. In this stage, individuals may use defense mechanisms to cope with the overwhelming emotions associated with their diagnosis or prognosis. The statement "The doctors must have made a mistake" is an example of denial as the individual refuses to accept the diagnosis and instead attributes it to an error by medical professionals.

A. 1 B. 4 C. 15 D. 10

Correct Answer is B

Explanation

The PCA (patient-controlled analgesia) pump is programmed to deliver a dose of 0.5 mg of morphine every 15 minutes as needed. This setup means that only 1 dose can be administered every 15 minutes, regardless of how many times the patient presses the button.

Since 60 minutes have passed, the maximum number of doses the patient could receive is calculated as follows:

60 minutes/ 15 minutes per dose= 4 doses

Even though the patient pressed the button 10 times, the pump will only deliver a dose every 15 minutes, resulting in 4 doses.

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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

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

Correct Answer is C

Explanation

A patient is on a PCA pump following an abdominal surgery. The order states the client can have 0.5mg morphine every 15 minutes as needed. The client pushed the button 10 times in the past 60 minutes. How many doses did the client receive?

Correct Answer is B

Explanation

A patient has been prescribed a clear liquid diet. What food or fluids will be served?

What is the rationale for using continuous positive air pressure (CPAP) to treat sleep apnea?

A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?

Which of the following is the best example of a measurable client goal? The client will:

Which of the following would be falsification of health records? Select all that apply.

A new patient is admitted to a medical unit with Clostridium difficile (C-diff). Which type of precautions or isolation should the nurse apply for this patient?

A nurse is assisting a patient who is 2 days postoperative from an abdominal surgery to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient tells the nurse she feels faint. What should be the nurse's immediate action to keep the patient safe?

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?