the nurse is caring for a client who has dysphagia related to a stroke the nurse works with the client to explain what food and beverages might minimi the nurse is caring for a client who has dysphagia related to a stroke the nurse works with the client to explain what food and beverages might minimi
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NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?

Correct answer: Secondary prevention

Rationale: The nurse working with the client to explain what food and beverages might minimize aspiration is an example of secondary prevention. Secondary prevention involves early detection and intervention to prevent complications or worsening of a condition. In this case, the nurse is helping to prevent aspiration pneumonia by providing education and guidance on safe eating and drinking practices after the client has already experienced dysphagia due to a stroke. Choice A, health promotion, focuses on empowering individuals to adopt healthy behaviors to improve overall well-being and prevent illness. It is more about promoting general health rather than specific interventions related to a particular condition like dysphagia. Choice C, tertiary prevention, involves managing and rehabilitating a condition to prevent further complications or disabilities. In this scenario, the nurse is not yet addressing complications but rather actively preventing them. Choice D, primary prevention, aims to prevent the onset of a disease or condition before it occurs. The client in this case already has dysphagia, so the focus is on preventing further complications, making it a secondary prevention intervention.

2. When evaluating the lab work of a client in hepatic coma, which of the following lab tests is most important?

Correct answer: serum ammonia

Rationale: When a client is in hepatic coma due to liver failure, the liver cannot metabolize amino acids completely, leading to elevated ammonia levels. Increased ammonia can cause brain-tissue irritation, worsening the coma. Therefore, monitoring serum ammonia levels is crucial in assessing the severity of hepatic coma. Choices A, B, and D are less relevant in the context of hepatic coma. Blood urea nitrogen primarily assesses kidney function, serum calcium levels are not directly related to hepatic coma, and serum creatinine is more indicative of kidney function rather than liver function in this scenario.

3. A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse anticipates that this client would be in which acid-base imbalance?

Correct answer: Respiratory alkalosis

Rationale: The correct answer is respiratory alkalosis. Hyperventilation due to anxiety, pain, shock, severe infection, fever, or liver failure can lead to respiratory alkalosis. In this scenario, the client is extremely anxious and crying uncontrollably, indicating an increased respiratory rate and CO2 loss. Respiratory acidosis (choice A) is incorrect as it is characterized by an increase in CO2 levels, not a loss. Metabolic acidosis (choice C) involves a decrease in blood pH due to an accumulation of acids or loss of bicarbonate, which is not the case here. Metabolic alkalosis (choice D) results from excess bicarbonate or a loss of acids, not from increased CO2 loss due to hyperventilation.

4. When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing:

Correct answer: 2–3 teaspoons of honey

Rationale: The correct immediate intervention for hypoglycemia is to provide 10–15 grams of fast-acting simple carbohydrates orally if the client is conscious and able to swallow. This can be achieved by giving 2–3 teaspoons of honey. Honey is a quick source of simple sugars that can rapidly raise blood glucose levels. Commercially prepared glucose tablets or 4–6 ounces of fruit juice are also appropriate options. However, adding sugar to fruit juice is unnecessary as the natural fruit sugar in juice already provides enough simple carbohydrates to raise blood glucose levels. Hard candies are not the best choice for immediate intervention in hypoglycemia as they may not provide a sufficient amount of fast-acting carbohydrates needed to raise blood sugar levels quickly.

5. A pregnant client is being educated by a nurse on nutrition and foods rich in folic acid. Which food item does the nurse inform the client contains the highest amount of folic acid?

Correct answer: Pinto beans

Rationale: Pinto beans contain the highest amount of folic acid among the options provided, with 294 mcg per 1-cup serving. Oranges contain 44 mcg per 1-cup serving, lettuce contains 60 mcg per 1-cup serving, and broccoli contains 78 mcg per 1-cup serving. Therefore, pinto beans are the best choice for increasing folic acid intake during pregnancy. Choosing oranges, lettuce, or broccoli would not provide as much folic acid compared to pinto beans, making them less optimal choices for meeting folic acid requirements during pregnancy.

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