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 :

Blank 1: Aspiration

🟦The client is showing clear signs of dysphagia, including food “getting stuck in the mouth” and a hoarse or wet vocal quality, which strongly indicates impaired swallowing.

🟦Dysphagia increases the risk that food, fluids, or saliva may enter the airway instead of the esophagus, leading to aspiration.

🟦Aspiration is especially dangerous in clients with neurological deficits, such as mild left-sided weakness, which may indicate a recent cerebrovascular event affecting swallowing coordination.

🟦The change in vital signs from Day 1 to Day 2—particularly increasing heart rate, temperature, and respiratory rate—could signal early aspiration-related inflammation or infection, such as aspiration pneumonia.

🟦Because aspiration poses a risk to airway protection and oxygenation, early identification and preventive measures are critical.

❌ INCORRECT ANSWERS ELABORATED

❌ Blank 1: Sepsis

🟥 Why This Is Incorrect:

🟥Sepsis results from a systemic infection, usually accompanied by fever, tachycardia, hypotension, and significant clinical deterioration.

🟥While the client’s temperature increased slightly, the findings do not indicate a systemic infection—there is no leukocytosis, hypotension, altered mental status, or other hallmark signs of sepsis.

🟥Mild changes in vital signs can be attributed to normal physiologic variation or stress, not sepsis.

🟥The primary concern from the assessment findings is airway protection, not infection spreading throughout the bloodstream.

❌ Blank 1: Tachycardia

🟥 Why This Is Incorrect:

🟥Tachycardia is an isolated symptom, not a risk condition. The question asks for a risk the client faces, not for a description of a vital sign.

🟥A heart rate increase from 78 to 88/min is mild and can reflect normal variation, pain, anxiety, or slight dehydration—not a condition requiring risk labeling.

🟥Tachycardia does not align with the symptoms of dysphagia or aspiration risk.

❌ Blank 2: Prescribed medications

🟥 Why This Is Incorrect:

🟥The client's medications (metoprolol and simvastatin) do not cause dysphagia or lead directly to aspiration risk.

🟥Prescribed medications are irrelevant to the symptoms observed: difficulty swallowing and hoarse voice.

🟥The question requires a clinical finding, not a medication list, to support the risk.

❌ Blank 2: Oxygenation

🟥 Why This Is Incorrect:

🟥The client’s O₂ saturation on Day 1 and Day 2 remained 96–100%, which is normal and does not indicate impaired oxygenation.

🟥No shortness of breath, cyanosis, or respiratory distress was reported.

🟥Dysphagia—not oxygenation—is the clearest evidence pointing toward aspiration risk.

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Answer 2

Correct Answers:

Oxygen saturation
Blood pressure
Clients request for information
Clients PO intake

Rationale :

💎 Oxygen saturation — ✅ REPORT

💎 The client’s oxygen saturation dropped from 97% to 92% on room air over three days, which is a significant change, even though 92% is still borderline acceptable.

💎 A new decrease in oxygen saturation could indicate developing respiratory compromise, underlying pulmonary issues, or reduced reserve, which is important information before anesthesia.

💎 Combined with anxiety and tachycardia, this drop might signal a stress response, impaired gas exchange, or early cardiopulmonary concerns.

💎 Preoperative providers and anesthesia must know about any change in oxygenation to decide if further evaluation (e.g., ABG, chest imaging, or delay in surgery) is needed.

⭐ Blood pressure — ✅ REPORT

⭐ The client’s blood pressure has increased from 126/74 mm Hg to 158/96 mm Hg, which is now in the hypertensive range.

⭐ Elevated blood pressure increases the risk of intraoperative and postoperative complications, such as bleeding, cardiac events, or stroke during anesthesia.

⭐ Even though anxiety may contribute, this level of hypertension still needs provider notification so they can decide whether to proceed, medicate, or delay surgery.

⭐ Preoperative stability is essential for safe anesthesia induction, so significant changes in blood pressure must be reported.

🟢 Client’s request for information — ✅ REPORT / ACT ON

🟢 The client is requesting information about risks and benefits of surgery, which signals that they may not fully understand the procedure.

🟢 For informed consent to be valid, the client must understand the nature, risks, benefits, and alternatives of the procedure, and this explanation must come from the provider/surgeon, not the nurse.

🟢 While this doesn’t mean surgery must be canceled outright, it must be reported so the provider can return to the bedside and clarify, reinforcing true informed consent.

🟢 If the client still has questions, proceeding with surgery would be ethically and legally problematic, making this a critical finding to communicate.

🔷 Client’s PO intake — ✅ REPORT

🔷 The client reports eating toast, coffee, and scrambled eggs at 0730 on the morning of surgery, which violates usual NPO (nothing by mouth) guidelines before general anesthesia.

🔷 Solid food is typically restricted for at least 6–8 hours prior to surgery to reduce the risk of aspiration when the airway is unprotected under anesthesia.

🔷 This is a critical safety issue and must be reported so the provider and anesthesia team can decide whether to delay or reschedule the procedure.

🔷 Proceeding with surgery after a recent solid meal puts the client at risk of regurgitation and aspiration pneumonia during intubation.

🔹 WBC count — ❌ Do NOT report (assuming normal)

❌ The scenario does not highlight any abnormal WBC value or signs of systemic infection such as high fever, chills, or purulent drainage.

❌ If the WBC were elevated or very low, it would absolutely be important before surgery, but here it is mentioned only as a routine lab.

❌ In exam items, labs not flagged as abnormal are usually considered to be within expected range.

❌ Therefore, the WBC count is not one of the key findings that must be reported based on the information provided.

🔹 Abdominal findings — ❌ Do NOT report as a concern

❌ The abdominal assessment shows a soft, rounded, nondistended abdomen with no tenderness and active bowel sounds in all four quadrants, which are normal findings for a preoperative client.

❌ The client reports a formed bowel movement yesterday, suggesting normal gastrointestinal functioning without constipation or obstruction.

❌ There is no guarding, rigidity, rebound tenderness, or signs of acute abdomen, so nothing here suggests a reason to delay surgery.

❌ Because all abdominal findings are within expected limits, there is no need to specifically report them as a problem to the provider.

🔹 Blood type — ❌ Do NOT report as a concern

❌ Having a documented blood type is an expected part of preoperative workup, especially for surgeries where there is some bleeding risk.

❌ The presence of a blood type in the chart is not an abnormal finding and does not in itself signal a problem.

❌ It is information used for transfusion planning, not something that indicates deterioration or a reason to cancel surgery.

❌ Therefore, it is not a “report this as a concern” finding—it's simply routine pre-op data.

🔹 Capillary refill — ❌ Do NOT report

❌ Capillary refill less than 2 seconds is normal and indicates adequate peripheral perfusion.

❌ There are no signs of shock, dehydration, or vascular compromise in the extremities based on this finding.

❌ It supports the conclusion that circulation is stable, even with an elevated BP.

❌ Because this is a reassuring assessment, it is not a concern to report to the provider.

🔹 Platelet count — ❌ Do NOT report (assuming normal)

❌ Nothing in the scenario suggests that the platelet count is abnormal; it is simply listed as part of routine lab data.

❌ If the platelet count were low (thrombocytopenia), that would certainly be reportable due to bleeding risk—but this is not indicated.

❌ In exam-style questions, lab values that are not highlighted as abnormal are typically assumed to be within normal range.

❌ A normal platelet count is expected pre-op and not something that requires urgent reporting.

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Answer 3

Correct Answers:

"Drink a glass of milk before bedtime."

Rationale :

🟦 Drinking a glass of milk before bedtime can promote sleep because milk contains tryptophan, an amino acid that supports relaxation and drowsiness.

🟦 A light snack such as milk helps prevent nighttime hunger, which can interrupt sleep.

🟦 This strategy is non-stimulating and supports a calming bedtime routine.

🟦 It fits recommended sleep hygiene practices by avoiding vigorous activity or stimulating activities before bed.

❌ Incorrect Options

❌ Long walk before bedtime — stimulates the body and increases alertness.

❌ One-hour nap daily — long naps can worsen insomnia and disrupt nighttime sleep cycles.

❌ Watching TV in bed — blue light interferes with melatonin and conditions the brain to associate the bed with wakefulness, not sleep.

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Answer 4

Correct Answers:

Decreased edema formation

Rationale :

❄️ Cold therapy causes vasoconstriction, which reduces blood flow to the area and limits edema formation after injury or surgery.

❄️ By slowing circulation, cold helps minimize inflammatory fluid from accumulating in the tissues.

❄️ It also decreases tissue metabolism, which further reduces swelling and pain.

❄️ Cold therapy is commonly used immediately after surgery or trauma to control swelling and promote comfort.

❌ Incorrect Options

❌ Increased tissue metabolism — cold decreases metabolism.

❌ Improved blood flow — cold reduces blood flow; heat increases it.

❌ Reduced blood coagulation — cold promotes vasoconstriction and supports coagulation, not reduces it.

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Answer 5

Correct Answers:

Blood pressure 88/62 mm Hg
Decreased skin turgor
Dry mucous membranes

Rationale :

✔ Blood pressure 88/62 mm Hg — Indicates fluid volume deficit

💧 A low blood pressure like 88/62 mm Hg is a classic sign of fluid volume deficit (hypovolemia) because reduced circulating volume leads to poor perfusion.

💧 When fluid losses from vomiting continue for 48 hours, intravascular volume decreases, lowering blood pressure.

💧 Hypotension is especially common when the body cannot compensate for the loss through vasoconstriction alone.

💧 This is a key hemodynamic indicator of dehydration, requiring prompt evaluation and fluid replacement.

✔ Decreased skin turgor — Indicates fluid volume deficit

💧 Poor skin turgor occurs when the body's interstitial fluid stores are depleted, making the skin lose elasticity.

💧 Vomiting for 48 hours significantly decreases fluid within tissues, leading to delayed return of the skin when pinched.

💧 This sign is especially reliable in the elderly and in clients with prolonged fluid losses.

💧 It is one of the most common physical exam findings used to assess dehydration.

✔ Dry mucous membranes — Indicates fluid volume deficit

💧 When the body is fluid-depleted, it prioritizes maintaining vital organ perfusion, leading to reduced moisture in mucous membranes.

💧 A 48-hour history of vomiting results in significant fluid and electrolyte loss, producing dryness of the oral cavity.

💧 Dry mucous membranes are a reliable early indicator of dehydration.

💧 This symptom supports the diagnosis of fluid volume deficit, especially when combined with other signs like hypotension.

❌ Incorrect Answers Explained

❌ Heart rate 72/min — NOT a sign of deficit

A heart rate of 72/min is normal and does not reflect hypovolemia.

Clients with fluid volume deficit typically have tachycardia, not normal heart rates, because the body attempts to compensate for low blood volume.

A normal rate therefore does not support dehydration.

❌ Distended neck veins — NOT a sign of deficit

Distended neck veins occur in fluid volume excess, heart failure, or increased central venous pressure.

A dehydrated client would more likely have flat neck veins, not distended ones.

Therefore, distension does not indicate fluid volume deficit and contradicts the expected findings.

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Answer 6

Correct Answers:

Borborygmi

Rationale :

🟦 Borborygmi are loud, gurgling, growling bowel sounds produced by hyperactive intestinal movement.

🟦 They occur when gas and fluid move rapidly through the intestines, often heard during hunger, diarrhea, or after eating.

🟦 This term precisely describes loud, rumbling sounds noted during auscultation, making it the correct documentation choice.

🟦 It does not indicate pathology alone but reflects increased bowel activity.

❌ Incorrect Options

❌ Distention — refers to swelling or enlargement of the abdomen, not bowel sounds.

❌ Paralytic ileus — bowel paralysis leading to absent bowel sounds, not loud ones.

❌ Hypoactivity — describes decreased bowel sounds, opposite of the finding.

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Answer 7

Correct Answers:

"l can revise my living will if I change my mind."

Rationale :

📘 A living will is a legal document expressing a client’s wishes regarding medical treatment if they become unable to decide.

📘 Clients retain full control and may revise or revoke the living will at any time while competent.

📘 This ensures autonomy and allows the document to reflect current beliefs or preferences.

📘 The nurse must reinforce that the client—not family, physicians, or attorneys—controls the content.

❌ Incorrect Options

❌ Family can change decisions — they cannot override the client’s legal document.

❌ Doctor will choose procedures — the provider must follow the client’s documented wishes.

❌ Need an attorney — not required; clients may complete a living will independently following state guidelines.

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Answer 8

Correct Answers:

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

Rationale :

✔ Apply clean gloves

🟢 Wearing clean gloves is part of standard precautions, which protect both the nurse and the client during any contact with blood.

🟢 Even though a capillary puncture is a minor procedure, it still involves potential exposure to bloodborne pathogens, making gloves essential.

🟢 Gloves also prevent contamination of the puncture site, promoting infection control and maintaining aseptic technique.

🟢 Using gloves aligns with universal safety guidelines established by regulatory bodies such as OSHA and the CDC.

✔ Prick the side of the client’s finger

🟣 The side of the fingertip contains fewer nerve endings than the central pad, which reduces pain during the puncture.

🟣 This location provides adequate capillary blood flow without causing unnecessary trauma to sensitive areas.

🟣 Using the side also minimizes bruising and soreness, especially in clients who require frequent monitoring such as diabetics.

🟣 This technique is considered evidence-based practice for obtaining accurate and comfortable capillary samples.

❌ INCORRECT OPTIONS

❌ Cleanse the client’s finger with an iodine swab

🔴 Why Incorrect:

🔴 Iodine is not recommended for capillary sampling because it can interfere with certain blood tests, especially glucose readings.

🔴 The appropriate antiseptic for a finger stick is 70% alcohol, which evaporates quickly and does not alter laboratory values.

🔴 Iodine takes longer to dry and increases the risk of contaminating the sample if not fully removed.

🔴 Using iodine may also irritate sensitive skin and is only used in specific procedures—not routine capillary testing.

❌ Squeeze the client’s finger until a drop forms

🔴 Why Incorrect:

🔴 Excessive squeezing can cause hemolysis, breaking red blood cells and altering the test accuracy.

🔴 It may also dilute the blood with interstitial fluid, producing false low glucose readings.

🔴 Only gentle pressure near the puncture site should be used to encourage natural blood flow.

🔴 Over-squeezing increases discomfort and should be avoided in best-practice technique.

❌ Elevate the client’s hand above heart level

🔴 Why Incorrect:

🔴 Elevating the hand decreases blood flow to the fingers, making it harder to obtain an adequate drop of blood.

🔴 For optimal sample collection, the hand should be kept dependent (below heart level) to promote perfusion.

🔴 Raising the hand can result in delayed collection and repeated attempts, increasing discomfort.

🔴 Proper positioning supports both client comfort and test accuracy.

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Answer 9

Correct Answers:

use a catheter securing device to hold the catheter in place.

Rationale :

🟩 A catheter-securing device prevents accidental pulling or displacement of the indwelling catheter, which reduces urethral trauma.

🟩 Securing the catheter also decreases the risk of catheter-associated urinary tract infections (CAUTIs) by minimizing movement at the urethral insertion site.

🟩 Stabilization helps maintain a closed drainage system, which is essential for infection prevention.

🟩 This follows evidence-based catheter-care guidelines to promote comfort and safety.

❌ Incorrect Options Explained

❌ Change the catheter bag every 3 days and as needed

Bags are not routinely changed every 3 days; they are changed only when contaminated or per policy, to reduce infection risk.

Frequent unnecessary disconnections break the sterile closed system.

This increases the chance of bacteria entering the urinary tract.

Therefore, this action does not support proper catheter care.

❌ Position the drainage bag higher than the client’s bladder

Doing so allows backflow of urine, increasing the risk for infection.

The drainage bag must always be below bladder level to promote gravity drainage.

Incorrect positioning can cause retrograde contamination.

This is a major CAUTI risk and must be avoided.

❌ Obtain urine from the drainage bag if a urine specimen is required

The drainage bag contains old, stagnant urine, which compromises specimen accuracy.

Urine specimens must be collected from the sampling port after cleaning it with antiseptic.

Using urine from the bag may lead to false results or contamination.

Therefore, this is unsafe practice.

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Answer 10

Correct Answers:

The client is positioned to minimize pressure on the skin.

Rationale :

🟦 Proper positioning prevents pressure injuries, nerve damage, and compromised circulation during surgery.

🟦 Clients under anesthesia cannot reposition themselves, making careful padding and alignment essential.

🟦 Positioning also protects respiratory and cardiovascular function by avoiding compression of the chest or major vessels.

🟦 Ensuring pressure relief supports a safe, therapeutic, and complication-free operative environment.

❌ Incorrect Options Explained

❌ The client is covered with a cooling blanket during surgery

Cooling blankets are not routine and are used only in specific hyperthermia cases.

More commonly, clients are kept warm, not cool, to prevent hypothermia.

Hypothermia increases bleeding risk and delays recovery.

This does not support standard safe surgical care.

❌ The client's surgical site is shaved with a razor

Razors create microabrasions that increase postoperative infection risk.

Hair removal should be done with clippers, not razors.

Surgical guidelines advise avoiding shaving unless absolutely necessary.

Therefore, this action does not support safety.

❌ The grounding pad is positioned near the client’s surgical site

Grounding pads must be placed on a well-vascularized, muscular area, not near the incision.

Incorrect placement can cause burns during electrosurgery.

The pad must be positioned away from bony prominences and surgical prep areas.

This also fails to support safe operative 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 in a provider’s office is collecting data from an adult client. The client states that they are having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?

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

5 :
A nurse in a provider’s office is reviewing the medical record of a client who reports having nausea and vomiting for the last 48 hr. Which of the following findings indicate fluid volume deficit? (Select all that apply.)

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

9 :
A nurse is assisting with the care of a client who had an indwelling urinary catheter inserted 3 days ago. 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 identity 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 in a provider’s office is collecting data from an adult client. The client states that they are having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?

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

5 : A nurse in a provider’s office is reviewing the medical record of a client who reports having nausea and vomiting for the last 48 hr. Which of the following findings indicate fluid volume deficit? (Select all that apply.)

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

9 : A nurse is assisting with the care of a client who had an indwelling urinary catheter inserted 3 days ago. 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 identity 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 in a provider’s office is collecting data from an adult client. The client states that they are having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?

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

5 :
A nurse in a provider’s office is reviewing the medical record of a client who reports having nausea and vomiting for the last 48 hr. Which of the following findings indicate fluid volume deficit? (Select all that apply.)

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

9 :
A nurse is assisting with the care of a client who had an indwelling urinary catheter inserted 3 days ago. 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 identity as supporting a safe therapeutic environment?