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. Yogurt with fruit:

While yogurt with fruit is a soft and easily digestible option, it is not representative of a progression from a clear liquid diet to a full liquid diet. Yogurt is typically included in a full liquid diet, but the addition of fruit may introduce solid particles. The transition from clear to full liquids usually involves avoiding solid or textured foods.

B. Pudding:

Pudding is a suitable choice that aligns with the progression from a clear liquid diet to a full liquid diet. Pudding is a smooth and creamy food, making it appropriate for someone transitioning from clear liquids. It provides a source of calories and is easy to swallow, meeting the criteria for a full liquid diet.

C. Cooked vegetables:

Cooked vegetables are not part of a full liquid diet. While they are a healthy food choice, they are too textured for someone transitioning from a clear liquid diet. Full liquid diets focus on foods that are liquid at room temperature or become liquid when they reach body temperature.

D. Bananas:

Bananas are a soft and easily digestible fruit, but they are not typically included in a full liquid diet. The texture of bananas may be too thick for someone progressing from a clear liquid diet, and they are not considered a liquid or a food that becomes liquid at room temperature.

A. Check that the client has a small gauge IV catheter in place. B. Check the blood product's compatibility with the client's blood type. C. Prime the client's primary IV tubing with lactated Ringer's. D. Confirm the identity of the client with the blood bank technician.

Correct Answer is B

Explanation

A. Check that the client has a small gauge IV catheter in place:

While it is important to have an appropriate-sized IV catheter for blood transfusions, checking the compatibility of the blood product with the client's blood type is the primary concern before initiating the transfusion. The IV catheter size becomes relevant after confirming compatibility.

B. Check the blood product's compatibility with the client's blood type:

This is the first and most crucial step before administering any blood product. Ensuring compatibility between the packed red blood cells (PRBCs) and the client's blood type is vital to prevent a transfusion reaction. The nurse should carefully check the blood product against the client's

C. Prime the client's primary IV tubing with lactated Ringer's:

Priming the tubing with lactated Ringer's is not the first step. The initial focus should be on verifying the compatibility of the blood product with the client's blood type. After ensuring compatibility, the nurse can then prime the tubing with the appropriate blood product.

D. Confirm the identity of the client with the blood bank technician:

Confirming the identity of the client with the blood bank technician is important, but it is not the first step before the start of the infusion. The immediate priority is to check the compatibility of the blood product with the client's blood type. Confirming the client's identity becomes crucial during the administration process.

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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

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