A nurse is caring for a client who has dysphagia following a stroke. Which of the following
actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? --
----ANSWER IS-----Delay the clients meal-time if he is fatigued.
(To facilitate safe swallowing and decrease the risk of aspiration, the nurse should encourage
the client to test prior to meal-time. If the client is fatigued, the nurse should delay the mealtime and give the client time to rest.)
A nurse is teaching the parent of a toddler about home injury prevention. When discussing
snacks, which of the following statements by the parent indicates an understanding of the
teaching? ------ANSWER IS-----"I can give her watermelon pieces after I remove the seeds."
(The nurse should inform the parent that toddlers can easily choke on seeds from fruits, such as
watermelon seeds or cherry pits, because of their round shape and size. Removing the seeds
and cutting the watermelon into pieces provides the toddler with a nutritious snack that does
not increase the toddler's risk of foreign body obstruction.)
A nurse is asked by a provider to perform an invasive procedure for which he has not received
training. Which of the following actions should the nurse take to ensure that it is within his legal
scope of practice to perform this procedure? ------ANSWER IS-----Check the states nurse practice
act before performing the procedure.
(The nurse should check the state's nurse practice act to verify that performance is within his
scope of practice. This will ensure that the nurse follows legal guidelines for his scope of
practice. If the nurse works in more than one state, he should check the nurse practice act for
each state, because guidelines for this procedure might differ from state to state. If the
procedure is within the nurse's scope of practice, he should take necessary steps to gain
competence in the procedure before performing it on a client.)
A nurse is caring for a older adult client who has a leg wound following a fall on the stairs. The
nurse would identify which of the following factors as an expected, age-related change in older
adults that can impair wound healing? ------ANSWER IS-----Elastin fibers separate and thicken.
(The nurse should identify that elastin fibers in an older adult client thicken and separate, which
can cause delayed wound healing and lead to a "saggy" appearance due to decreased skin
elasticity.)
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