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 D
Explanation
Choice A rationale
Applying cornstarch powder to the perineal area can lead to clumping and skin irritation, especially in a moist environment. It is not recommended for managing fecal incontinence.
Choice B rationale
Turning the client every 4 hours is important for preventing pressure ulcers but does not directly address fecal incontinence. Frequent turning should be combined with other measures for skin protection.
Choice C rationale
Cleansing the perineal area with povidone-iodine solution can be harsh and drying to the skin. It is not typically recommended for routine care of fecal incontinence.
Choice D rationale
Placing a moisture barrier ointment over the perineal area protects the skin from irritation and breakdown caused by fecal matter. It creates a protective layer, which is essential in managing fecal incontinence.
Correct Answer is C
Explanation
Choice A rationale
Assessing pain levels is a nursing task requiring clinical judgment, which is beyond the scope of an assistive personnel's duties.
Choice B rationale
Checking an IV site for redness or swelling also requires clinical assessment skills, which are tasks for the nurse.
Choice C rationale
Measuring intake and output is a routine task that can be safely delegated to an assistive personnel. It involves straightforward measurement and recording.
Choice D rationale
Reinforcing teaching about crutch-gait walking requires specific patient education, which falls under the nurse's responsibilities.
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