A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?

Rapid chewing

Garbled voice

Sneezing

Increased hunger

Answer and Explanation

The Correct Answer is B

A. Rapid chewing is not specific to dysphagia.

B. A garbled or "wet" voice is often a sign of dysphagia, as it can indicate difficulty with swallowing and risk for aspiration.

C. Sneezing is not typically associated with swallowing difficulties.

D. Increased hunger is unrelated to dysphagia and does not indicate difficulty swallowing.

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Correct Answer is A

Explanation

A. Using a filter needle to aspirate the medication from an ampule is appropriate because it prevents glass particles from entering the syringe when the ampule is broken.

B. Injecting air into an ampule is unnecessary and can be dangerous as ampules are designed to be opened directly without air injection.

C. Cleansing the tip of the ampule should occur before opening it, not after, to ensure sterility is maintained.

D. Adding diluent is not a standard practice unless the specific medication requires reconstitution as directed by a healthcare provider.

A. Use a 10-mL syringe filled with cleansing solution. B. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound. C. Cleanse the wound with cotton balls. D. Dry the wound bed with gauze squares.

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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A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Correct Answer is A

Explanation

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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