A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?

A client who needs assistance when ambulating.

A client who consistently has difficulty using utensils while eating.

A client who has expressive aphasia.

A client who consistently coughs after drinking liquids.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D.

Choice A rationale: Ambulation assistance is expected in rehabilitation. It reflects motor recovery needs but does not pose an immediate safety or health risk requiring urgent referral.

Choice B rationale: Difficulty using utensils indicates fine motor deficits. While important for occupational therapy, it’s not a priority compared to airway protection concerns.

Choice C rationale: Expressive aphasia affects communication but does not compromise physical safety or airway integrity. Speech therapy is appropriate but not urgent.

Choice D rationale: Coughing after drinking signals aspiration risk. This can lead to pneumonia or airway obstruction, requiring immediate referral to speech-language pathology for swallow evaluation.

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Correct Answer is D

Explanation

Choice A rationale:

Using a 5-mL syringe to flush the catheter is not the best choice. Central venous access devices typically require a larger syringe for flushing to prevent excessive pressure and potential damage to the catheter. A smaller syringe like the 5-mL syringe can create higher pressure, which could cause complications.

Choice B rationale:

Changing the site dressing and stabilization device every 24 hours is not the recommended practice. The dressing and stabilization device should be changed according to facility policy and as needed, but a rigid 24-hour schedule is not necessary and might increase the risk of infection due to unnecessary exposure.

Choice C rationale:

Expecting blood to appear in the catheter lumen after flushing is incorrect. Blood in the catheter lumen after flushing could indicate complications such as a dislodged catheter or other issues requiring immediate attention. The catheter should ideally remain patent without the presence of blood.

Choice D rationale:

This is the correct choice. Using chlorhexidine solution to clean the catheter is an evidence-based practice to prevent infection at the insertion site. Chlorhexidine has broad-spectrum antimicrobial properties and helps reduce the risk of catheter-related infections.

A. Metabolic acidosis. B. Respiratory acidosis. C. Metabolic alkalosis. D. Respiratory alkalosis.

Correct Answer is C

Explanation

Choice A rationale:

Metabolic acidosis is not the correct acid-base imbalance for the given ABG results. Metabolic acidosis is characterized by a low pH (acidic), low bicarbonate (HCO3) levels, and a compensatory decrease in the PaCO2. In the provided ABG results, the pH is elevated, and both the PaCO2 and HCO3 levels are within normal ranges.

Choice B rationale:

Respiratory acidosis is also not the correct acid-base imbalance for the given ABG results. Respiratory acidosis occurs when there is an elevation in PaCO2 due to inadequate ventilation, leading to an acidic pH. In the provided ABG results, the pH is elevated, and the PaCO2 level is within normal range.

Choice C rationale:

Metabolic alkalosis is the correct acid-base imbalance for the given ABG results. Metabolic alkalosis is characterized by an elevated pH, elevated bicarbonate (HCO3) levels, and a compensatory increase in PaCO2. In this case, the pH is higher than the normal range, the HCO3 level is elevated, and the PaCO2 is also slightly increased as the body attempts to compensate.

Choice D rationale:

Respiratory alkalosis is not the correct answer based on the provided ABG results. Respiratory alkalosis is marked by an elevated pH and a decrease in PaCO2 due to excessive ventilation. In the given ABG results, the pH is elevated, but the PaCO2 is not decreased; it's within the normal range.

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A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a central venous access device. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reviewing the ABG results for a client. The client's results are pH 7.47, PaCO2 30 mm Hg, HCO3 25 mEq/L, and SaO2 90%. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

Correct Answer is C

Explanation

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