A nurse is assisting with the care of a client who had a stroke.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
- Mucous membranes pink, skin warm and dry.
- Coughing and clearing throat when eating.
- Voice hoarse after swallowing.
- Temperature 38 °C (100.4 °F)
- Bilateral breath sounds with wheezing heard in upper lobes.
- Oxygen saturation 88% on room air
Mucous membranes pink, skin warm and dry.
Coughing and clearing throat when eating.
Voice hoarse after swallowing.
Temperature 38 °C (100.4 °F)
Bilateral breath sounds with wheezing heard in upper lobes.
Oxygen saturation 88% on room air
The Correct Answer is ["B","C","D","E","F"]
- Mucous membranes pink, skin warm and dry.
- Coughing and clearing throat when eating.
- Voice hoarse after swallowing.
- Temperature 38 °C (100.4 °F)
- Bilateral breath sounds with wheezing heard in upper lobes.
- Oxygen saturation 88% on room air
Rationale
Coughing and clearing throat when eating: This indicates potential dysphagia (difficulty swallowing), which increases the risk of aspiration pneumonia—a serious complication post-stroke.
Voice hoarse after swallowing: Hoarseness or voice changes can also signal impaired swallowing or aspiration risk, necessitating evaluation by a speech therapist or further swallowing studies.
Temperature 38.5°C (101.3°F): An elevated temperature may suggest infection (e.g., aspiration pneumonia or another complication) and warrants further investigation, particularly in a post-stroke client.
Bilateral breath sounds with wheezing heard in upper lobes: Wheezing could indicate an airway obstruction, aspiration, or developing respiratory compromise, which is critical in this population.
Oxygen saturation 88% on room air: Hypoxemia is a critical finding requiring immediate intervention, such as supplemental oxygen and investigation into the underlying cause (e.g., aspiration, infection, or pulmonary embolism).
Mucous membranes pink, skin warm and dry: These findings are within normal limits and do not indicate a pressing issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Warm the enema solution to prevent discomfort and potential injury from a cold solution.
B. Clean technique is used when administering enemas, not sterile technique.
C. The left lateral position is preferred for enema administration.
D. An oil-based lubricant is not recommended for enema tubing; a water-based lubricant is preferred.
Correct Answer is A
Explanation
A. Case managers are responsible for coordinating care, including arranging for services such as home health care, ensuring continuity of care after discharge.
B. Writing prescriptions is outside the scope of case management and is a responsibility of licensed providers such as physicians or nurse practitioners.
C. Performing nursing tasks, such as dressing changes, is a role carried out by bedside nurses or home health care nurses, not case managers.
D. Providing education about medications is typically the responsibility of bedside nurses, as they are more directly involved in client education during care.
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