A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?

The client tucks his chin while swallowing food.

The client sits upright in bed during meals.

The client pockets food on one side of his mouth.

The client has a cough reflex.

Answer and Explanation

The Correct Answer is C

A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.

B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.

C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.

D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.

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Correct Answer is A

Explanation

A. "Your PICC line will allow long-term access for antibiotic therapy." - PICC lines are often used for long-term administration of medications, including antibiotics, due to their durability and ease of use.

B. "You should use a 5-milliliter barrel syringe to flush your PICC line at home." - The size of the syringe used to flush a PICC line depends on the facility's protocol and the client's specific

needs. Specific instructions regarding syringe size should be provided by the healthcare provider or nurse.

C. "Your PICC line must be placed in your nondominant arm." - The choice of arm for PICC line placement depends on various factors, including vein integrity and the client's comfort. There is no strict requirement for the PICC line to be placed in the nondominant arm.

D. "You should immobilize the arm with the PICC line using a sling." - Immobilizing the arm with a sling is not typically necessary after PICC line placement. Clients are usually instructed to avoid excessive movement and to keep the arm clean and dry to prevent complications.

A. Serum calcium 10 mg/dL B. Urine specific gravity 1.001 C. Serum sodium 138 mEq/L D. Urine pH 6.1

Correct Answer is B

Explanation

A. Serum calcium levels are not directly indicative of hypervolemia.

B. A urine specific gravity of 1.001 indicates dilute urine, which is a common finding in hypervolemia as the kidneys attempt to excrete excess fluid.

C. Serum sodium levels within the normal range (e.g., 138 mEq/L) are not indicative of hypervolemia.

D. Urine pH of 6.1 is within the normal range and does not specifically indicate hypervolemia.

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A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?

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