A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

The client is consuming 25% of their meals.

The client coughs frequently while eating.

The client's blood pressure is 142/94 mm Hg.

The client leans to the left side while sitting.

Answer and Explanation

The Correct Answer is B

A. The client is consuming 25% of their meals.

Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.

B. The client coughs frequently while eating.

Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.

C. The client's blood pressure is 142/94 mm Hg.

The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.

D. The client leans to the left side while sitting.

Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.

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Correct Answer is B

Explanation

A. Case manager:

The nurse manager, in this context, is not functioning as a case manager. Case management typically involves coordinating and managing the overall care plan for a client over time, including coordination of resources and services.

B. Client care provider:

The nurse manager, in this scenario, is functioning as a client care provider. By observing the newly licensed nurse perform a straight catheterization, the nurse manager is directly involved in overseeing and ensuring the safety of the client care being provided.

C. Client advocate:

While advocacy for the client is a crucial role for all nurses, the specific action described (observing the procedure) is more aligned with the role of a client care provider. Advocacy involves supporting and safeguarding the client's rights and well-being, which can be done in various nursing roles.

D. Client educator:

The nurse manager is not functioning as a client educator in this specific situation. Client education involves providing information and instruction to the client to promote their understanding and participation in their care. The nurse manager's role here is more focused on direct observation and supervision of a clinical skill.

A. Assist the client with a bowel cleansing. B. Ensure the client is free of metal objects. C. Monitor the client for pain in the suprapubic region. D. Administer 240 mL. (8 oz) of oral contrast before the procedure

Correct Answer is A

Explanation

A. Assist the client with a bowel cleansing.A bowel cleansing is necessary before an intravenous pyelogram (IVP) to ensure the urinary tract is clearly visualized on the X-ray images. Residual stool or gas in the intestines can obscure the view of the kidneys, ureters, and bladder.

B.Ensure the client is free of metal objects.While ensuring the client is free of metal objects is critical for procedures involving magnetic resonance imaging (MRI) or X-rays of the skeletal system, it is not specifically required for an IVP.

C.Monitor the client for pain in the suprapubic region.Monitoring for suprapubic pain is more relevant after procedures such as catheterization or bladder studies, or in cases of suspected urinary retention or infection.

D.Administer 240 mL (8 oz) of oral contrast before the procedure.An IVP involves injecting contrast dye intravenously, not orally. Oral contrast is typically used for gastrointestinal studies, such as a CT scan of the abdomen or barium swallow.

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A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?

Correct Answer is B

Explanation

A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

Correct Answer is A

Explanation

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