for a client requiring total oral care it is important for the nurse to

NCLEX-PN

Next Generation Nclex Questions Overview 3.0 ATI Quizlet

1. For a client requiring total oral care, it is important for the nurse to:

A. assemble all equipment, assist the client to a semi-Fowler's position, and place a towel on his chest.
B. place the client in Fowler's position, prepare the equipment, and instruct the client what to do.
C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
D. use gloves and clean the client's mouth, including the tongue.

Correct answer: C

Rationale: To provide total oral care to a client, the nurse should first assemble all necessary equipment. Placing the client in a side-lying position helps fluids to easily flow out or pool in the side of the mouth for suctioning, thus preventing aspiration. Additionally, placing a towel under the client's chin and a curved basin against the chin helps to maintain cleanliness during the procedure. Choice A is incorrect because the client should be placed in a side-lying position, not a semi-Fowler's position which is used for respiratory issues. Choice B is incorrect as it does not emphasize the importance of proper positioning for effective oral care. Choice D is incorrect as it oversimplifies the procedure by focusing only on cleaning the mouth without considering the importance of positioning and preparation.

2. A client with a nasogastric (NG) tube begins vomiting. What action should the nurse take?

A. Retape the NG tube.
B. Clamp the NG tube.
C. Remove the NG tube.
D. Check the NG tube placement.

Correct answer: D

Rationale: When a client with a nasogastric (NG) tube begins vomiting, the nurse should first check the NG tube placement. Vomiting can be a sign of tube displacement, which can lead to serious complications. Retaping the tube (Choice A), clamping it (Choice B), or removing it (Choice C) without first assessing its placement can be harmful or ineffective. Checking the NG tube placement is crucial as it ensures that the tube is in the correct position and prevents potential complications. Retaping the NG tube (Choice A) is incorrect because the priority is to check the placement first. Clamping the NG tube (Choice B) or removing it (Choice C) without verifying the placement can be dangerous if the tube is dislodged. Thus, these actions should not be taken before confirming the tube's position.

3. A director of nursing at a long-term care center has announced a change to computerized documentation of nursing care. A certified nursing assistant (CNA) on the team, resistant to the change, is not taking an active part in facilitating the implementation of the new procedure. Which strategy would be the best approach to dealing with the conflict?

A. Meeting with the CNA and encouraging him to express his feelings regarding the change
B. Ignoring the resistance
C. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs
D. Telling the CNA that noncompliance will be documented in the personnel record

Correct answer: A

Rationale: The best approach to dealing with resistance to change is through open communication and understanding. Meeting with the CNA and encouraging him to express his feelings regarding the change allows for a constructive dialogue where issues can be addressed, and alternative solutions can be explored. Ignoring the resistance does not help in resolving the conflict and may lead to further issues. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs does not address the underlying concerns of the CNA and may create more resistance. Threatening the CNA with noncompliance consequences may escalate the resistance and create a negative work environment.

4. The client is going for surgery and mentions their religious objection to blood transfusions. Which of the following responses would be most appropriate?

A. "I can ask pastoral care to send someone to speak with you about this concern since it would not be safe to refuse a blood transfusion."?
B. "I understand, and you have the right to refuse blood transfusions."?
C. "While I understand, if there is excessive bleeding during surgery, we may need to transfuse blood to stabilize you."?
D. "I have received a blood transfusion before, and I do not think you understand the risks versus the benefits of refusing this."?

Correct answer: B

Rationale: The most appropriate response is, '"I understand, and you have the right to refuse blood transfusions."? This answer shows respect for the client's autonomy and religious beliefs. It is crucial for healthcare providers to acknowledge and support a patient's decision-making regarding their care, even if it conflicts with medical advice. Option A is not ideal as it might seem dismissive of the client's beliefs. Option C introduces a potential negative outcome of refusing a blood transfusion, which could induce fear or coercion. Option D is inappropriate because it implies judgment and does not uphold the client's autonomy.

5. After administering medication through an NG tube, the client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?

A. You can lie down in 1 hour.
B. You can lie down in 5 minutes if your NG residual is below 50 mLs.
C. You can lie down in about 30 minutes.
D. Yes, feel free to lie down.

Correct answer: C

Rationale: The correct answer is to inform the client that they can lie down in about 30 minutes. After administering medication through an NG tube, it is recommended that the client remains upright for about 30 minutes to ensure proper absorption of the medications. Option A is incorrect as waiting for 1 hour is unnecessary. Option B is incorrect as the specified timeframe and condition given are not standard practice for lying down after NG tube medication administration. Option D is incorrect as it lacks guidance on the appropriate waiting time and does not emphasize the importance of waiting before lying down for optimal medication absorption.