A nurse is assisting with the care of a male client in the unit.
Complete the following sentence by using the list of options.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Choice A rationale:
While hoarseness can be a symptom of aspiration pneumonia, it is not a direct cause. Hoarseness alone does not necessarily lead to aspiration pneumonia.
Choice B rationale:
Coughing when eating is a direct risk factor for aspiration pneumonia. Coughing indicates that food or liquid may be entering the airway, which can lead to aspiration pneumonia.
Choice C rationale:
Dysphagia (difficulty swallowing) can be a risk factor for aspiration pneumonia, but in this case, the client's symptoms (coughing when eating and hoarseness) are more directly associated with aspiration pneumonia.
Choice D rationale:
While coughing when eating can be a symptom of dysphagia, the primary concern here is the risk of aspiration pneumonia due to the same symptom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Using a quick-release tie to secure the restraint is standard practice as it ensures the restraint can be removed quickly in case of an emergency, ensuring patient safety.
Choice B rationale
Tying the restraint to the bed frame is appropriate because it prevents the client from removing the restraint independently while still allowing for quick-release if necessary. It ensures the client's safety by securing the restraint to a stable part of the bed.
Choice C rationale
Placing the restraint across the client's chest requires intervention because it can restrict breathing and cause serious harm. This practice is unsafe and contraindicated in restraint use guidelines.
Choice D rationale
Applying the restraint over the client's gown is correct as it provides a barrier between the skin and the restraint, reducing the risk of skin irritation or injury.
Correct Answer is D
Explanation
Choice A rationale
Verifying the bilirubin level of the tube contents is not a standard or reliable method for checking the placement of a feeding tube. Bilirubin is a bile pigment found in the liver and bile ducts, and its levels are not indicative of tube placement in the gastrointestinal tract.
Choice B rationale
Checking the pH level of gastric contents can help determine if the tube is in the stomach, but it is not the most reliable method. Gastric pH is typically acidic (1.5-3.5), but the pH can vary, and this method does not rule out respiratory placement or other incorrect placements.
Choice C rationale
Auscultating for air insufflation involves listening for the sound of air injected through the tube into the stomach. However, this method is not reliable as it does not confirm the exact location of the tube and can give false positives if the tube is in the esophagus or respiratory tract.
Choice D rationale
Requesting a chest x-ray is the most reliable method for verifying feeding tube placement. It provides a clear visual confirmation of the tube's location, ensuring it is correctly positioned in the stomach or small intestine and not in the respiratory tract or other incorrect locations.
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