A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Aspiration (Option 1): The client's report of feeling food stuck in their mouth, along with the noted hoarseness, indicates difficulty swallowing (dysphagia), which puts them at risk for aspiration. Aspiration occurs when food or liquid enters the airway instead of the esophagus, which can lead to serious complications, including pneumonia.
Dysphagia (Option 2): The presence of dysphagia, or difficulty swallowing, directly supports the risk for aspiration. If the client is unable to swallow safely, there is an increased likelihood of aspiration occurring during eating or drinking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","":"C"}
Explanation
Hyperglycemia: The client's blood glucose levels are elevated, as indicated by the notation of hyperglycemia on Day 3. The symptoms of lethargy, thirst, and frequent urination further support the presence of hyperglycemia, which is often associated with parenteral nutrition due to its high glucose content.
Dehydration: The symptoms of lethargy and frequent urination can also indicate dehydration. The client’s thirst suggests a compensatory mechanism in response to potential fluid loss or insufficient fluid intake. Since parenteral nutrition can sometimes lead to imbalances if not monitored closely, dehydration is a possible concern in this scenario.
Correct Answer is B
Explanation
A. A 10-mL syringe is typically too small for effective wound irrigation; a larger syringe (30 mL or more) is usually recommended to provide adequate pressure and volume for cleansing.
B. Holding the syringe tip 2.5 cm (1 in) above the wound ensures that the irrigation solution is delivered effectively without directly contaminating the wound.
C. Cotton balls should not be used for wound cleansing, as they can leave fibers behind; gauze pads or sterile swabs are more appropriate.
D. The wound bed should not be dried with gauze; instead, it should remain moist or be covered with appropriate dressings to promote healing.
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