A client with dysphagia and at risk for aspiration needs care planning. Which intervention should the nurse include in the plan?

Correct Answer: D

Rationale: Placing the client in Fowler's position is crucial in preventing aspiration as it helps maintain an open airway and reduces the risk of food or liquid entering the lungs during swallowing. This position promotes safer swallowing and minimizes the chances of aspiration pneumonia.

Correct Answer: C

Rationale: High-pitched gurgles in the RLQ are typical normal bowel sounds.

Correct Answer: A

Rationale: Post-tracheostomy, the obturator (A) is essential at the bedside to reinsert the tube if dislodged, ensuring airway patency. An oral airway (B) is irrelevant for tracheostomy patients. Epinephrine (C) treats allergic reactions, not routine needs. A larger tracheostomy tube (D) isn't standard emergency equipment. A is correct. Rationale: The obturator facilitates immediate tube replacement, critical in the first 72 hours before a tract forms, preventing airway loss, a priority per surgical nursing standards over other less relevant items.

Correct Answer: D

Rationale: Brown rice is a whole grain that is high in fiber, making it an excellent choice for a high-fiber diet. Foods like white bread, canned fruit, and cheese are typically low in fiber and would not be the best recommendation for a high-fiber diet.

Correct Answer: B

Rationale: Professional boundaries maintain appropriate limits (B), per ethics e.g., no romance. Not personal (A), not patient-only (C, staff too), not all (D) distance-focused. B truly defines boundaries' role, like with Mr. Gary, making it correct.

Correct Answer: A

Rationale: The deltoid muscle is a common site for intramuscular injections in adults due to its accessibility and muscle mass. It is located in the upper arm and provides a sufficient area for injection. The deltoid muscle is preferred for administering vaccines and other medications that require IM administration.

Correct Answer: C

Rationale: The planning phase of the nursing process culminates in the creation of a nursing care plan, which outlines specific, measurable goals and interventions tailored to the patient's needs. This plan serves as a roadmap for the implementation phase, ensuring care is individualized and goal-directed. The nursing history, collected during assessment, provides background data but isn't the outcome of planning. Nursing notes document ongoing care and observations, occurring throughout the process, not specifically as a planning product. The nursing diagnosis, formulated in the diagnosis phase, identifies problems but precedes planning; it informs the care plan rather than being its outcome. By producing a nursing care plan, the planning phase bridges assessment and action, enabling nurses to address patient needs effectively and evaluate progress, making it the clear and logical result of this critical step in the nursing process.

Correct Answer: A

Rationale: Nuts are an excellent source of protein and are suitable for a high-protein diet. They provide essential nutrients and can help the client meet their increased protein requirements.

Correct Answer: D

Rationale: Clients on potassium-sparing diuretics need to avoid high-potassium foods to prevent hyperkalemia. Apples are a low-potassium fruit, making them a suitable recommendation for clients on this type of diuretic.