A nurse is updating a plan of care for a client who has dysphagia. What intervention should the nurse include?

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Question 1 of 5

A nurse is updating a plan of care for a client who has dysphagia. What intervention should the nurse include?

Correct Answer: C

Rationale: The correct intervention for a client with dysphagia is to have them sit upright for 1 hour after meals. This position helps facilitate swallowing and reduces the risk of aspiration, which is crucial in managing dysphagia. Encouraging the client to lie down after eating (Choice A) can increase the risk of aspiration. Offering liquids with meals (Choice B) may also increase the risk of aspiration as it can affect swallowing coordination. Providing the client with a straw for drinking (Choice D) is not recommended as straws can increase the risk of aspiration in individuals with dysphagia.

Question 2 of 5

A charge nurse is making assignments for the upcoming shift. Which client should the charge nurse assign to a licensed practical nurse (LPN)?

Correct Answer: C

Rationale: The correct answer is C because a client with dehydration and inflammatory bowel disease is stable enough for care by an LPN. This condition does not require complex interventions that would necessitate a higher level of nursing care. Choice A is incorrect as administering IV antibiotics for pneumonia requires a higher level of nursing expertise. Choice B is incorrect because monitoring for dehydration may involve assessing vital signs and making critical decisions. Choice D is incorrect as providing care for surgical wound care involves wound assessment, dressing changes, and monitoring for signs of infection, which typically require a registered nurse.

Question 3 of 5

A nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration. What finding should the nurse intervene for?

Correct Answer: B

Rationale: A heart rate of 120 beats per minute indicates tachycardia, which can be a sign of dehydration and requires intervention. A heart rate of 80 beats per minute is within the normal range and does not indicate dehydration. A blood pressure of 110/70 mmHg is considered normal. A respiratory rate of 16 breaths per minute is also within the normal range and does not point towards dehydration.

Question 4 of 5

While documenting client care, which entry should the nurse identify as an example of implementing client care?

Correct Answer: D

Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.

Question 5 of 5

A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?

Correct Answer: A

Rationale: The correct answer is A: Negligence. Negligence in nursing occurs when a healthcare provider fails to take appropriate action that a reasonably prudent provider would take in a similar situation, such as not notifying the provider of changes in a client's condition. In this scenario, the nurse's failure to inform the provider of the client's changed condition constitutes negligence. Choices B, C, and D are incorrect. Assault involves the intentional threat of bodily harm to another person, battery is the intentional harmful or offensive touching of another person without their consent, and defamation is the act of making false statements about someone to a third party that harms that person's reputation.

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