A nurse is caring for a client.

Nurses' Notes

Heart rate

0800:

Antibiotics administered as prescribed.

Bilateral breath sounds clear and present throughout.

0830:

The client reports itching over the chest area and has urticaria over the chest and trunk.

The client states tongue feels swollen.

Bilateral breath sounds with scattered wheezing upon auscultation.

Select the 4 findings that require immediate follow-up.

Swollen tongue

Heart rate

Breath sounds

Blood pressure

Temperature

Urticaria

Answer and Explanation

Correct Answer : A,B,C,F

A.Swollen tongue: Swelling of the tongue can indicate an allergic reaction, which could progress to a severe condition known as anaphylaxis. Immediate intervention is necessary.

B. Heart rate: While the heart rate is not directly mentioned in the notes, an increase in heart rate could be a physiological response to an allergic reaction or anaphylaxis. Monitoring heart rate is crucial in assessing the severity of the reaction.

C. Bilateral breath sounds with scattered wheezing upon auscultation: Wheezing indicates a potential respiratory issue, and when associated with itching, urticaria, and swelling, it suggests an allergic reaction or anaphylaxis. Prompt intervention is needed.

D. Blood pressure: Although blood pressure is important to monitor, it is not directly mentioned in the nurses' notes. However, if anaphylaxis or a severe allergic reaction is suspected, blood pressure can be affected, and it should be monitored.

E. Temperature: Fever is not mentioned in the notes, and the information provided suggests an immediate allergic reaction rather than an infectious process. Monitoring temperature is generally important but may not be a priority in this specific context.

F.Urticaria (hives): Hives are a sign of an allergic reaction and, when accompanied by other symptoms like swelling, require immediate attention.

Nursing Test Bank

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Correct Answer is B

Explanation

"Most people are scared their first time in a health care facility":

While this statement normalizes the client's feelings by suggesting that many people feel scared initially, it might not directly address the client's specific concerns or provide the opportunity for a personalized discussion about their stay.

"We can discuss what you can expect during your stay":

This statement acknowledges the client's anxiety and opens the door for a conversation about the client's concerns. It provides an opportunity for the nurse to offer information, address specific worries, and offer support, fostering a sense of control for the client.

"You have nothing to worry about. Everything will be fine":

This statement, though well-intentioned, may come across as dismissive and overly optimistic. It might not validate the client's feelings or offer the opportunity for the client to express and discuss their concerns.

"Why are you feeling scared about being in this facility?":

While open-ended questions can help explore the client's feelings, in this context, it might be better to initially offer information and support before delving into the specific reasons for the client's anxiety. This allows the nurse to establish rapport and provide reassurance first.

A. The client tucks their chin when they swallow. B. The client adjusts the head of their bed to 90°. C. The client drinks their thickened juice with a straw. D. The client takes frequent breaks while eating.

Correct Answer is C

Explanation

A. The client tucks their chin when they swallow:
This is a proper swallowing technique. Tucking the chin helps close off the airway during swallowing, reducing the risk of aspiration. It facilitates the safe passage of food or liquids into the esophagus
B. The client adjusts the head of their bed to 90°:
This action is appropriate. Keeping the head of the bed elevated to 30 to 45 degrees is recommended for clients with dysphagia as it helps prevent aspiration during swallowing.
C. The client drinks their thickened juice with a straw:
This action indicates a potential problem. The use of a straw with thickened liquids is generally not recommended for clients with dysphagia. Thickened liquids are used to slow down the flow of the liquid and reduce the risk of aspiration. Drinking thickened juice through a straw may compromise the effectiveness of thickening and increase the risk of aspiration.
D. The client takes frequent breaks while eating:
This action is also appropriate. Clients with dysphagia may need to take breaks between bites to ensure safe and effective swallowing. It allows the client to pace themselves and reduces the risk of aspiration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

Correct Answer is C

Explanation

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