Learning System 3.0 NCLEX RN ATI

A nurse is assisting a client who has dysphagia with eating meals. Which of the following actions should the nurse take? Add water to soup for a thinner consistency Encourage using water to clear the client's mouth Ask the client to think of a food that produces salivation Remind the client to rest after meals

Ask the client to think of a food that produces salivation To prevent dryness in the mouth during meals, which can be a risk factor for choking, the nurse should ask the client to think of a food that promotes salivation - Lemon slices - Dill pickles A) Thick liquids are easier for clients who have dysphagia to manage when swallowing B) Clients who have dysphagia should only drink fluids after clearing the mouth of food. They should use coughing and dry swallowing to remove food particles from the mouth D) Clients who have dysphagia should rest BEFORE meals to avoid fatigue when focusing on swallowing safely

Using high-quality monitoring tools, a facility committee identifies that clients who have congestive HF have an average length of stay of 5 days instead of the established standard of 3 days. A) Educate staff members on shortening the length of stay for these clients B) Collect data regarding the length of stay for these clients C) Determine which actions can be instituted to address this problem D) Research the accuracy of the standard of care that has been accepted

C) Determine which actions can be instituted to address this problem Further analysis of data will identify factors that contribute to longer lengths of stay. Identifying actions to shorten the clients' lengths of stay is the next step in the process Collect data First analyze the data Extensive research Standards of care are established

A nurse is caring for a 12 m.o. infant following the surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments? Spoon Straw Firm nipple Cup

Cup The infant should be fed clear liquids using a cup for 7-10 days following a cleft palate repair to prevent trauma and injury to the suture line.

A nurse is performing a mental status examination on a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly? A. Subtract by 7 serially, starting at 100 B. Describe a previous illness C. Explain what to do if a fire happened in his bedroom D. Discuss the meaning of a common proverb

D. Discuss the meaning of a common proverb This part of the mental-status examination evaluates the client's ability to think abstractly. A) attention span B) remote memory C) judgement

A nurse is caring for a client who is undergoing conservative treatment for DVT. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? Your body has a process called fibrinolysis that will eventually dissolve the clot Your body has a mechanism that will keep the clot stable in its present location The clot will break into tiny fragments and float harmlessly in your blood Treatment with heparin will dissolve the clot and keep other clots from forming

Fibrinolysis is a process that breaks down a clot over time in the body. This process is a treatment option for clots that are not immediately life-threatening. Heparin does not dissolve clots. It prevents enlargement of the existing clots and future clot formation. Thrombolytic therapy, not anticoagulant therapy, dissolves clots.

A nurse is teaching a client who has TB about a new Rx for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

I can expect this med to turn my skin orange

A nurse is explaining lactation suppression to a client whose newborn will be bottle-fed. Which of the following client statements indicates an understanding of the teaching? I should lightly massage my breasts when I feel discomfort I should express a small amount of milk if my breasts feel tight I should take a warm shower twice a day I should wear a support bra for a few days

I should wear a support bra for a few days Nurse should instruct the client to wear a support bra that fits securely. Wearing this bra continuously for the first 3 days postpartum helps promote suppression of lactation A) Avoid stimulation of breasts B) Avoid expressing breast milk C) Avoid running warm water on the breasts. The warm water promotes, rather than suppresses, lactation.

A nurse is assessing a school-aged child who has acute glomerulonephritis. Which of the following manifestations should the nurse expect? Hypokalemia Decreased BP Increased urine volume Periorbital edema

Periorbital edema A manifestation of acute glomerulonephritis - Swelling is usually worse in the mornings and spreads throughout the day to the genitalia, abdomen, and extremities B) The BP in acute glomerulonephritis may suddenly become dangerously high

A nurse is reviewing a new prescription for fexofenadine for a 7-year-old client who has seasonal allergies. Which of the following findings should the nurse clarify with the provider? The prescription says to avoid taking the medicine with orange juice. The prescription says to take standard tablets. The prescription says to take 30 mg twice daily The prescription says to administer the medicine orally

The prescription says to take standard tablets. The nurse should identify that this 7-year-old client has been prescribed a standard tablet, which is appropriate for clients 12 years of age and older. Therefore, the nurse should clarify this aspect of the prescription with the provider because a client who is 7 years old should be administered orally disintegrating tablets or a suspension A) Therapeutic effect of fexofenadine is decreased when taken with OJ C) The nurse can administer fexofenadine 30 mg twice daily, which is appropriate dosage for a 7-year-old.child d) Route is PO

A nurse is caring for a client who takes Warfarin 2.5 mg PO daily and has an INR of 6.2. The nurse should anticipate a prescription from the provider for which of the following meds? Protamine sulfate Fondaparinux Vitamin K Bivalirudin

Vitamin K A) Protamine sulfate --> antidote administered for severe HEPARIN OD B) Fondaparinux --> anticoagulant med D) Bivalirudin --> IV anticoagulant