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Q1: A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?
Answer Choices:
A. Elevate the client's head of the bed to 45° during meals.
B. Alternate the client's liquids and solids during meals.
C. Instruct the client to tilt their head back while swallowing.
D. Turn on the client's television during meals.
Correct Answer: Alternate the client's liquids and solids during meals.
Rationale:
💊 Alternating liquids and solids during meals is correct because it helps clear the client’s throat, reduces food sticking in the pharynx, and lowers the risk of aspiration—this promotes safer swallowing.
💊 Elevating the client’s head of the bed to 45° during meals is incorrect because the head should actually be at least 90° (upright) to reduce aspiration risk.
💊 Instructing the client to tilt their head back while swallowing is incorrect because this increases the risk of aspiration—clients with dysphagia should use the chin-tuck technique instead.
💊 Turning on the client’s television during meals is incorrect because distractions increase aspiration risk; mealtimes should remain calm and focused.
Q2: A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
Answer Choices:
A. Position the client supine.
B. Deflate the balloon halfway and then pull out the catheter.
C. Have the client bear down during removal.
D. Cleanse the perineal area with an antiseptic.
Correct Answer: Position the client supine.
Rationale:
🩺 Positioning the client supine is correct because it provides comfort, proper visualization, and access to the urinary meatus for safe catheter removal.
🩺 Deflating the balloon halfway and then pulling out the catheter is incorrect because the balloon must be completely deflated before removal to prevent urethral trauma.
🩺 Having the client bear down during removal is incorrect because this is not necessary and could actually increase discomfort.
🩺 Cleansing the perineal area with an antiseptic is incorrect because cleansing is part of catheter insertion, not removal—the balloon must be deflated first.
Q3: A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?
Answer Choices:
A. Add thickener to fluids.
B. Place food on the left side of the client's mouth.
C. Serve food at room temperature.
D. Instruct the client to tilt her head back when she swallows.
Correct Answer: Add thickener to fluids.
Rationale:
💉 Adding thickener to fluids is correct because thickened liquids are easier to control in the mouth and throat, reducing the risk of aspiration in clients with dysphagia.
💉 Placing food on the left side of the client’s mouth is incorrect because the client has left-sided weakness—food should be placed on the stronger (right) side to aid chewing and swallowing.
💉 Serving food at room temperature is incorrect because temperature does not affect swallowing safety, though varying food temperature and texture can sometimes stimulate swallowing reflexes.
💉 Instructing the client to tilt her head back when she swallows is incorrect because this increases aspiration risk—the safer method is a chin-tuck position.
Q4: A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first?
Answer Choices:
A. Lubricate the catheter.
B. Arrange the sterile items on the sterile field.
C. Explain to the client that she will feel temporary discomfort.
D. Clean the perineum from front to back.
Correct Answer: Explain to the client that she will feel temporary discomfort.
Rationale:
🩺 Explaining to the client that she will feel temporary discomfort is correct because the first step is always client education and providing emotional support before performing any invasive procedure—this promotes cooperation and reduces anxiety.
🩺 Lubricating the catheter is incorrect because this is done later in the procedure after sterile preparation.
🩺 Arranging the sterile items on the sterile field is incorrect because this comes after the nurse has explained and prepared the client.
🩺 Cleaning the perineum from front to back is incorrect because this is part of the sterile technique that occurs after preparing and positioning the client.
Q5: A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?
Answer Choices:
A. Urinary frequency
B. Urinary tract infection
C. Urinary retention
D. Urinary incontinence
Correct Answer: Urinary tract infection
Rationale:
💊 Urinary tract infection is correct because dark amber, cloudy urine with an unpleasant odor are classic indicators of infection, often accompanied by bacteria and white blood cells in the urine.
💊 Urinary frequency is incorrect because it refers to how often the client urinates, not the urine’s appearance or smell.
💊 Urinary retention is incorrect because it means urine remains in the bladder, but when released it is not typically cloudy or foul-smelling unless infection is also present.
💊 Urinary incontinence is incorrect because it refers to loss of bladder control and does not alter urine’s color or odor.
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