The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement?

Assist the client to lie down and turn to the side.

Recommend the use of supplemental liquid feedings.

Demonstrate use of a tucked-chin position while eating.

Encourage the use of assistive feeding devices.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assisting the client to lie down may increase the risk of aspiration.

Choice B reason: Supplemental liquid feedings may be considered but do not address the immediate issue.

Choice C reason: Demonstrating the tucked-chin position can help reduce the risk of aspiration by ensuring the airway is protected during swallowing.

Choice D reason: Assistive feeding devices may help but do not address the immediate issue of frequent coughing during meals.

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Correct Answer is ["3.3"]

Explanation

Calculation Steps:

Step 1: Convert weight from pounds to kilograms: 22 pounds ÷ 2.2 = 10 kg. Result = 10 kg.

Step 2: Calculate the total daily dose of amoxicillin: 50 mg/kg/day × 10 kg = 500 mg/day. Result = 500 mg/day.

Step 3: Calculate the dose per administration: 500 mg/day ÷ 3 doses/day = 166.7 mg/dose. Result = 166.7 mg/dose.

Step 4: Determine how many mL are needed for each dose: 250 mg/5 mL = 50 mg/mL, 166.7 mg ÷ 50 mg/mL = 3.3 mL. Result = 3.3 mL.

A. Monitor daily sodium intake. B. Measure ankle circumference. C. Obtain serum creatinine levels daily. D. Ensure client takes a diuretic every morning.

Correct Answer is A

Explanation

Choice A reason: Monitoring daily sodium intake is crucial because SIADH often leads to hyponatremia (low sodium levels). Keeping track of sodium intake helps manage and prevent complications associated with sodium imbalances, such as seizures or confusion.

Choice B reason: Measuring ankle circumference can help assess fluid retention, but it is not the first intervention. It is more important to address the underlying issue of sodium imbalance.

Choice C reason: Obtaining serum creatinine levels daily can provide information about kidney function but does not directly address the immediate concern of sodium and fluid balance in SIADH.

Choice D reason: Ensuring the client takes a diuretic every morning may be part of the treatment plan, but it is more important to first monitor and manage sodium levels to ensure safe and effective use of diuretics.

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The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["3.3"]

Explanation

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

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