Question

A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day.

Answer 1

Correct Answers

Blank 1 Correct Option: aspiration
Blank 2 Correct Option: dysphagia

Rationale :

🔷The client reports food feeling “stuck” and has a hoarse (wet) vocal quality, classic signs of oropharyngeal dysphagia indicating impaired airway protection during swallowing.

🔷Coexisting left-sided weakness suggests a recent neurologic insult (e.g., stroke) that can disrupt bulbar and laryngeal coordination, increasing the likelihood of penetration/aspiration of oral contents.

🔷In dysphagia, ineffective epiglottic closure and reduced laryngeal elevation allow residue in the valleculae and pyriform sinuses to spill into the airway, including silent aspiration without a strong cough.

🔷Early aspiration can present subtly (e.g., voice change, throat clearing, mild desaturation) before overt complications; here, the drop in SpO₂ from 100% → 96% plus a low-grade temperature rise may be early red flags in context.

🔷Preventing aspiration is a priority safety goal because it leads to aspiration pneumonia, hypoxemia, and respiratory failure; immediate measures include NPO until swallow screen, upright positioning (≥90°), oral care, and SLP evaluation.

🔷The presence of beta-blocker therapy (metoprolol) can blunt tachycardic responses to aspiration or infection, making clinical vigilance and objective screening even more critical to detect deterioration early.

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Answer 2

Correct Answers:

Platelet count
WBC count
Pain
Abdominal findings
Oxygen saturation

Rationale :

Platelet count

🔷Platelets are critical for hemostasis; a low count (e.g., <150,000/µL) heightens bleeding risk during or after procedures, while marked thrombocytosis can increase thrombotic risk.

🔷Abrupt postoperative changes can signal consumptive coagulopathy or heparin-induced thrombocytopenia (HIT) in recently exposed patients.

🔷Abnormal platelets also influence anesthesia/analgesia choices (e.g., neuraxial procedures) and wound healing.

🔷Because deviations can rapidly lead to hemorrhage or clot, the provider needs prompt notification to adjust the plan of care (labs, transfusion thresholds, anticoagulation).

🔷Trending the platelet count alongside clinical status helps preempt hemodynamic compromise and procedure delays.

WBC count

🔷A rising WBC count post-op is a key marker of infection or inflammatory stress, especially with new tachycardia and a temperature uptick.

🔷Early reporting allows evaluation for surgical site infection, pneumonia, UTI, or catheter-related sources.

🔷Elevated WBC in conjunction with hypoxemia (SpO₂ 92%) raises concern for pulmonary complications such as atelectasis or evolving pneumonia.

🔷Prompt action (cultures, imaging, antibiotics if indicated) helps prevent progression to sepsis and readmission.

🔷The WBC trend informs timing of interventions and disposition (home vs. observation).

Pain

🔷Uncontrolled or atypical pain is clinically significant: it drives a sympathetic surge (↑HR, ↑BP as seen here) and impairs deep breathing and ambulation, elevating risk for atelectasis and VTE.

🔷New, disproportionate, or localized pain can herald a post-op complication (e.g., hematoma, abscess, anastomotic leak).

🔷Reporting ensures reassessment, targeted analgesic optimization, and investigation for underlying pathology rather than masking symptoms.

🔷Effective pain control improves pulmonary toilet, mobility, and recovery metrics.

🔷Timely communication also prevents hypertensive urgency and cardiac strain in vulnerable patients.

Abdominal findings

🔷Abnormal abdominal exam (distension, guarding/rigidity, rebound, absent/hypoactive bowel sounds) may indicate ileus, bleeding, ischemia, or peritonitis.

🔷Even in outpatient settings, evolving tenderness or bloating post-procedure warrants early provider review to avert bowel obstruction or occult hemorrhage.

🔷Linking the exam to nausea, emesis, or pain escalation further prioritizes imaging/labs.

🔷Rapid identification and escalation can prevent hemodynamic instability and unplanned hospitalization.

🔷Because abdominal complications can progress quickly, the provider must be notified to direct next steps (NPO, fluids, imaging, consults).

Oxygen saturation

🔷The drop from 97% → 92% on room air meets a threshold for hypoxemia and signals impaired gas exchange.

🔷In the post-operative context, consider atelectasis, pulmonary embolism, or pneumonia, especially with concurrent tachycardia (110/min).

🔷Early notification enables interventions—titrated oxygen, incentive spirometry, ambulation, imaging—to reverse decline.

🔷Persistent hypoxemia increases risk of myocardial stress, delirium, and poor wound healing.

🔷Continuous monitoring plus prompt escalation reduces risk of acute respiratory deterioration.

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Answer 3

Correct Answers:

Determine the client's level of consciousness.

Rationale :

🔷When a nurse finds a client face down on the floor, the first priority is assessing the client’s neurological and overall status, starting with the level of consciousness (LOC).

🔷LOC provides critical information about airway, breathing, circulation, and possible head injury, which are immediate life-safety concerns.

🔷Without determining responsiveness, other interventions (e.g., repositioning, asking history) could delay recognition of a life-threatening emergency.

🔷Once LOC is assessed, the nurse can proceed to check airway patency, vital signs, injuries, and initiate emergency protocols if necessary.

🔷This approach follows the ABC framework (Airway, Breathing, Circulation) and ensures patient safety before secondary assessments.

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Answer 4

Correct Answers:

Decreased edema formation

Rationale :

💠Cold therapy (cryotherapy) works by causing vasoconstriction, which reduces capillary permeability and limits fluid leakage into tissues.

💠This helps control swelling and edema formation at the surgical or injury site.

💠Cold also decreases nerve conduction velocity, providing analgesic effects and reducing the client’s perception of pain.

💠By lowering local tissue metabolism, it prevents further injury in the acute phase.

💠The nurse applies cold therapy for short, intermittent periods to avoid tissue damage or frostbite while maximizing therapeutic effects.

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Answer 5

Correct Answers:

Measure daily weight.
Ambulate with gait belt.
Measure output.
Assist client on bedpan.

Rationale :

Measure daily weight:

🔷Daily weight is a routine, non-invasive measurement that can be safely delegated to assistive personnel (AP).

🔷It is especially important in a client with dehydration, since weight change is a sensitive indicator of fluid balance status.

🔷The nurse remains responsible for interpreting the results and correlating them with lab values and intake/output.

Ambulate with gait belt:

🔷Ambulation with a gait belt is within the scope of APs because it is a basic mobility and safety task.

🔷This client is at risk of orthostatic hypotension and falls due to dehydration, so AP assistance helps maintain safety.

🔷The nurse delegates the activity, but ensures the AP knows how to use the gait belt properly and when to report dizziness or unsteadiness.

Measure output:

🔷Monitoring urine and stool output is a standard task for APs and provides essential data for assessing hydration status.

🔷This information contributes to the nurse’s evaluation of fluid balance and kidney perfusion.

🔷APs can collect and record the measurements, while the nurse interprets trends in output relative to intake and lab results.

Assist client on bedpan:

🔷Helping a client with elimination needs is a basic task that falls within the AP’s role.

🔷It promotes comfort and dignity, while also facilitating accurate measurement of intake and output.

🔷The nurse ensures correct documentation and assesses the characteristics of the stool if clinically significant (e.g., watery, bloody).

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Answer 6

Correct Answers:

Borborygmi

Rationale :

🔷Borborygmi are loud, growling sounds caused by the movement of gas and fluid through the intestines.

🔷They are often heard when the bowel is hyperactive, such as with hunger, diarrhea, or gastroenteritis.

🔷This is different from hypoactive or absent bowel sounds, which may indicate ileus or obstruction.

🔷Using the correct medical terminology in documentation ensures clear communication among providers.

🔷Accurate recording helps in monitoring changes in gastrointestinal function over time.

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Answer 7

Correct Answers:

“I can revise my living will If I change my mind."

Rationale :

💠A living will is a legal document that allows a client to state their preferences for medical treatment if they become incapacitated.

💠Clients maintain the right to revise or revoke their living will at any time as long as they are mentally competent.

💠This autonomy ensures that care decisions reflect the client’s current wishes rather than past ones.

💠It is not dependent on attorneys, family overrides, or physician authority to dictate care.

💠Understanding this empowers clients to remain in control of their care planning.

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Answer 8

Correct Answers:

Apply clean gloves.
Prick the Side of the client's finger.

Rationale :

Apply clean gloves

🩸Wearing clean, non-sterile gloves upholds Standard Precautions, protecting both the client and nurse from bloodborne pathogen exposure during skin puncture.

🩸Gloves also help maintain aseptic technique, minimizing transfer of microorganisms to the puncture site and reducing the chance of specimen contamination.

🩸Because capillary sampling involves direct contact with blood, proper barrier protection is a safety-critical step rather than an optional one.

🩸Consistent glove use supports infection prevention across repeated glucose checks or point-of-care tests, especially in settings with high testing frequency.

🩸By maintaining a clean field and safe handling, gloves help ensure the accuracy and integrity of the collected specimen for clinical decision-making.

Prick the side of the client’s finger

🩸Using the lateral (side) aspect of the fingertip targets areas with fewer densely packed nerve endings, resulting in less pain and better client tolerance.

🩸The sides of the fingertip typically provide more reliable capillary flow, helping obtain an adequate sample without excessive pressure, which protects sample quality.

🩸Selecting an appropriate finger (often the 3rd or 4th digit) and a controlled lancet depth reduces risk of tissue trauma and improves repeatability of results.

🩸Accessing the lateral surface also avoids the more calloused center of the fingertip that can impair blood return and compromise sample collection.

🩸Together, proper site selection and technique support accurate point-of-care testing while maximizing client comfort and safety.

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Answer 9

Correct Answers:

Place the client in a supine position with the knees bent.

Rationale :

💎An eviscerated abdominal wound is a medical emergency requiring rapid stabilization.

💎Positioning the client supine with knees bent reduces abdominal muscle tension, preventing further protrusion of organs.

💎The next step is to cover the wound with sterile saline-moistened dressings, not dry ones, to keep exposed tissue moist.

💎The nurse must notify the surgeon immediately and prepare for emergency surgery.

💎Avoid actions like coughing or deep breathing, as they increase intra-abdominal pressure and worsen evisceration.

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Answer 10

Correct Answers:

The client is positioned to minimize pressure on the skin.

Rationale :

⭐During surgery, clients are often immobile for long periods, making them vulnerable to pressure injuries and impaired circulation.

⭐Proper positioning reduces risk of skin breakdown, nerve injury, and musculoskeletal strain.

⭐Safe positioning also ensures adequate airway alignment, perfusion, and access to the surgical site.

⭐This is a core component of maintaining a safe, therapeutic environment in the operating room.

⭐Other listed options (e.g., shaving with a razor) can increase infection risk and do not reflect best practice.

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QLexNursing

1 :
A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day.

Correct Answers

2 :
A nurse in an outpatient surgical center is assisting in the care of a client.

Answer Options

3 :
A nurse enters a dienes room and finds the client face down on the floor. Which of the following actions should the nurse take first?

4 :
A nurse is applying cold therapy to a client's face following oral surgery. The nurse should identify that which of the following is a therapeutic effect of cold therapy?

5 :
A nurse is assisting with the care of a client on the medical unit.

Answer Options

6 :
A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings. the nurse should use which of the following terms?

7 :
A nurse is reinforcing teaching with a client who is planning to complete a living will. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse preparing to obtain a capillary blood specimen from a dent. Which of the following actions should the nurse take? (Select all that apply.)

9 :
A nurse is preparing to assist in providing care for a client who has an eviscerated abdominal wound. Which of the following actions should the nurse take?

10 :
A nurse is assisting in the care of a client during surgery. Which of the following should the nurse identify as supporting a safe therapeutic environment?

QLexNursing

1 : A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day.

Correct Answers

2 : A nurse in an outpatient surgical center is assisting in the care of a client.

Answer Options

3 : A nurse enters a dienes room and finds the client face down on the floor. Which of the following actions should the nurse take first?

4 : A nurse is applying cold therapy to a client's face following oral surgery. The nurse should identify that which of the following is a therapeutic effect of cold therapy?

5 : A nurse is assisting with the care of a client on the medical unit.

Answer Options

6 : A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings. the nurse should use which of the following terms?

7 : A nurse is reinforcing teaching with a client who is planning to complete a living will. Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse preparing to obtain a capillary blood specimen from a dent. Which of the following actions should the nurse take? (Select all that apply.)

9 : A nurse is preparing to assist in providing care for a client who has an eviscerated abdominal wound. Which of the following actions should the nurse take?

10 : A nurse is assisting in the care of a client during surgery. Which of the following should the nurse identify as supporting a safe therapeutic environment?

1 :
A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day.

2 :
A nurse in an outpatient surgical center is assisting in the care of a client.

3 :
A nurse enters a dienes room and finds the client face down on the floor. Which of the following actions should the nurse take first?

4 :
A nurse is applying cold therapy to a client's face following oral surgery. The nurse should identify that which of the following is a therapeutic effect of cold therapy?

5 :
A nurse is assisting with the care of a client on the medical unit.

6 :
A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings. the nurse should use which of the following terms?

7 :
A nurse is reinforcing teaching with a client who is planning to complete a living will. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse preparing to obtain a capillary blood specimen from a dent. Which of the following actions should the nurse take? (Select all that apply.)

9 :
A nurse is preparing to assist in providing care for a client who has an eviscerated abdominal wound. Which of the following actions should the nurse take?

10 :
A nurse is assisting in the care of a client during surgery. Which of the following should the nurse identify as supporting a safe therapeutic environment?