21. A nurse is formulating a plan of care for a client receiving enteral feedings. Which nursing diagnosis is of highest priority for this client?
a. Altered nutrition,less than body requirement
b. High risk for aspiration
c. High risk for fluid volume deficit
22. A client with status asthmaticus is in severe respiratory distress. The nurse should maintain the client in which position?
a. Sitting upright
23. While visiting a client who is recovering from a cerebrovascular accident, the client’s husband asks the nurse, “Why does my wife have a splint on her hand?” The nurse explains that the splint is necessary to prevent:
a. Injury to the hand
b. Deformity of the hand
c. Muscle wasting in the hand
d. Edema of the hand
24. A client undergoes an open reduction and internal fixation to treat a fractured right hip. Five hours after surgery, the nurse should maintain the client’s affected leg in which position?
a. External rotation
25. Once a client who has had an episode with acute pancreatitis is able to resume regular meals, the most appropriate breakfast would include:
a. Tea, scrambled eggs, toast, and butter
b. Coffee, boiled egg, bacon, and a roll
c. Tea, banana, boiled egg, and toast
d. Apple juice, oatmeal with cream, and sausage
ANSWERS AND RATIONALE
21) B– Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Option a and b may be appropriate nursing diagnoses but are not the highest priority. Option c is not likely to occur in this client.
22) A- a client in asthmaticus should be placed in the position that best promotes air exchange. Sitting upright eases the motion of the diaphragm and promotes a patent airway.
23) B- after a CVA affecting the arm, fingers of the affected hand should be extended and the hand and wrist placed in a functional position to prevent deformity. (Be aware that in some instance handsplints may increase spasticity).
24) B- after surgery for a fractured hip, the affected leg should be placed in abduction, using an abduction splint or pillows placed between the legs to separate them. The other options may cause dislocation.
25) C- a low-fat, low alcohol, and caffeine-free diet, minimizes pancreatic stimulation.
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