A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

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Question 1 of 5

A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

Correct Answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this scenario. This helps maintain comfort and prevent dryness in clients with nasogastric tubes. Allowing the client to melt ice chips in the mouth may not address oral care needs effectively. Providing mints to freshen the breath is not the priority when the client needs oral care. Swabbing the mouth with glycerin swabs may not be as effective as performing thorough oral care with a tooth sponge.

Question 2 of 5

A 78-year-old client with diabetes is being taught how to care for his feet. Which statement by the client indicates a need for further education?

Correct Answer: A

Rationale: The correct answer is A. Soaking feet daily can lead to excessive moisture, which can increase the risk of skin breakdown or infection in diabetic clients. Choices B, C, and D are all correct statements for foot care in diabetic clients. Using a mirror for daily foot checks helps in early detection of any issues, applying lotion while avoiding the area between the toes helps keep the skin moisturized without creating a risk for fungal infections, and wearing properly fitting shoes is important to prevent pressure points and potential injuries.

Question 3 of 5

The nurse is developing a teaching plan for a client receiving chemotherapy. Which of the following should be the nurse's first priority?

Correct Answer: C

Rationale: The correct answer is C. Recognizing signs and symptoms of infection should be the nurse's first priority when developing a teaching plan for a client receiving chemotherapy. Chemotherapy often compromises the immune system, making patients more susceptible to infections. Early identification and prompt treatment of infections are crucial to prevent complications. Options A, B, and D are important aspects of care but recognizing signs of infection takes precedence due to the potential life-threatening consequences in clients undergoing chemotherapy treatment.

Question 4 of 5

A client is receiving treatment for glaucoma. Which class of medications is commonly used to decrease intraocular pressure?

Correct Answer: D

Rationale: Diuretics are commonly used to decrease intraocular pressure in clients with glaucoma. They work by reducing the production of aqueous humor in the eye or by increasing its outflow. Anticholinergics (Choice A) are not typically used in the treatment of glaucoma and can even increase intraocular pressure. Beta blockers (Choice B) are also commonly used in glaucoma treatment as they reduce aqueous humor production. Alpha blockers (Choice C) are not the first-line treatment for glaucoma and are not as commonly used as diuretics or beta blockers.

Question 5 of 5

The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?

Correct Answer: D

Rationale: In this scenario, the best care assignment for the client with a skin tear and hematoma is to supervise a nursing assistant for skin care. This ensures proper wound care while utilizing the skills of the nursing assistant effectively. Assigning an RN to supervise the nursing assistant is appropriate as it provides the necessary expertise for wound care supervision. Delegating complete care to an unlicensed assistive personnel may not be suitable for a client with specific wound care needs. Helping the client with self-care activities may not directly address the urgent need for proper wound care in this situation.

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