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1. A client has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?
- A. Providing a straw for consumption of liquids
- B. Encouraging larger bites
- C. Placing the client in semi-Fowler's position during meals
- D. Instructing the client to tilt head forward when swallowing
Correct answer: C
Rationale: Placing the client in semi-Fowler's position during meals is the correct intervention for a client with acute dysphagia. This position helps prevent aspiration by facilitating swallowing. Providing a straw for consumption of liquids (Choice A) can increase the risk of aspiration and is not recommended for clients with dysphagia. Encouraging larger bites (Choice B) can also increase the risk of choking and aspiration. Instructing the client to tilt the head forward when swallowing (Choice D) is not the recommended technique for managing dysphagia as it does not address the underlying issue effectively.
2. A client is on a 2,000-calorie American Diabetes Association (ADA) diet and substitutes whole milk with skim milk. Which of the following items can the client add to the oatmeal on his breakfast tray?
- A. One 1/8 teaspoon of salt
- B. One ounce of raisins
- C. One tablespoon of low-fat margarine
- D. One teaspoon of brown sugar
Correct answer: B
Rationale: The correct answer is one ounce of raisins. Raisins are a healthy option to add to oatmeal as they provide natural sweetness without added sugars. They are a good source of fiber and essential nutrients. Option A, one 1/8 teaspoon of salt, is not necessary for flavoring oatmeal. Option C, one tablespoon of low-fat margarine, may add unnecessary fat to the meal. Option D, one teaspoon of brown sugar, adds extra sugar, which should be limited in a diabetes-friendly diet.
3. The recommended daily fluid intake of patients maintained using hemodialysis is:
- A. 150 mL plus the volume of urinary output
- B. 500 mL plus the volume of urinary output
- C. 1000 mL plus the volume of urinary output
- D. 1500 mL plus the volume of urinary output
Correct answer: C
Rationale: The correct answer is C: 1000 mL plus the volume of urinary output. Fluid intake is typically restricted in hemodialysis patients to prevent fluid overload. The recommended daily fluid intake for these patients is 1000 mL plus any urinary output. Choice A (150 mL plus the volume of urinary output) is too low and would not provide enough fluid for these patients. Choice B (500 mL plus the volume of urinary output) is also insufficient. Choice D (1500 mL plus the volume of urinary output) is too high and may lead to fluid overload in hemodialysis patients.
4. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?
- A. Sensation of taste
- B. Sensation of pressure
- C. Sensation of smell
- D. Urge to defecate
Correct answer: B
Rationale: The correct answer is B: Sensation of pressure. Patients with ileostomy can determine how often their pouch should be drained by feeling the sensation of pressure. This is important as it helps prevent leakage or overflow of the pouch. The sensation of taste (choice A) and smell (choice C) are not typically used as gauges for draining the pouch in ileostomy patients. The urge to defecate (choice D) is not relevant in this context as patients with ileostomy do not pass stool through the rectum.
5. The law which regulated the practice of nursing profession in the Philippines is:
- A. R.A 9173
- B. LOI 949
- C. Patient’s Bill of Rights
- D. Code of Ethics for Nurses
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
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