Question

1. A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?

1. Inform the client they might experience a low-grade fever.
2. Provide the client with sips of water.
3. Check the client's gag reflex.
4. Instruct the client to report bleeding.

2. A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?

1. "I can't seem to get reading materials far enough away to see the words."
2. "I've noticed that there is a gray ring around the colored part of my eye."
3. "In the last day, I have had a severe headache and pain around my right eye."
4. "I'm having more difficulty telling the difference between blues and greens."

3. A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider?

1. Take tub baths instead of showers.
2. May place a small pillow under the head when sleeping.
3. May operate a motor vehicle when no longer taking analgesics.
4. Increase intake of fiber-rich foods.

4. A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching?

1. "I can keep my medication for 1 year before replacing it."
2. "I should discontinue this medication if I develop a headache."
3. "i can take up to five tablets in 15 minutes before seeking medical attention."
4. "I should lie down when I take this medication."

Answer 1

1. Answer: C. Check the client's gag reflex.

The nurse must check the client's gag reflex or esophageal reflex first before stopping NPO and giving sips of water. Sips of water can be given only after the return of the gag reflex.

The other three options come only after checking the gag reflex.

2. Answer: C. "In the last day, I have had a severe headache and pain around my right eye."

A nurse assessing an older adult client at a health fair should give priority to the above statement of the client regarding severe headache and pain behind the eyes.

The other three conditions are usually seen in old age.

3. Answer: C. May operate a motor vehicle when no longer taking analgesics.

A nurse preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider should clarify the above prescription with the provider, as the usual advice given in this case is not to drive a vehicle while wearing a halo device.

The other three options have the possibility of being given as advice to the patient.

4. Answer: D. "I should lie down when I take this medication."

A nurse providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin can consider the above client statement as an indication of the client's understanding of the teaching.

The other three options are not correct and can't be considered as an indication of the client's understanding of the teaching.