A nurse is caring for a client who had a stroke and has dysphagia. For which of the following complications should the nurse monitor the client?
Aspiration
Gastroesophageal reflux disease
Peptic ulcer disease
Dumping syndrome
The Correct Answer is A
Aspiration is a common complication in patients with dysphagia post-stroke due to impaired swallowing reflexes, leading to food or liquid entering the lungs.
Choice B reason: Gastroesophageal reflux disease could be a concern but is not directly related to dysphagia post-stroke.
Choice C reason: Peptic ulcer disease is not typically a complication of dysphagia post-stroke.
Choice D reason: Dumping syndrome is related to rapid gastric emptying post-meal, not dysphagia post-stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Troponin Troponin levels increase within 3-12 hours from the onset of chest pain, peak at 24-48 hours, and return to baseline over 5-14 days. Troponin is a protein found in cardiac muscle fibers that regulates muscular contraction. When heart muscle is damaged, as in the case of an MI, troponin is released into the bloodstream. The elevation of troponin levels is a key indicator of myocardial infarction and can be used to diagnose and assess the extent of heart muscle damage. Troponin is the most reliable laboratory value that is expected to be elevated following a myocardial infarction, making it the correct choice in this scenario.
Choice B: Aspartate aminotransferase (AST) AST is an enzyme found in high concentrations in the liver, heart, muscles, kidneys, and brain. It is released into the bloodstream when any of these tissues are damaged. While AST can be elevated in cases of MI, it is not as specific as troponin because it is present in many other tissues besides the heart.
Choice C: Serum amylase Serum amylase is an enzyme that helps digest carbohydrates and is primarily associated with the pancreas and salivary glands. Its elevation is not specifically related to myocardial infarction but can be seen in other conditions such as pancreatitis.
Choice D: Unconjugated bilirubin Unconjugated bilirubin is a breakdown product of hemoglobin from red blood cells. Elevated levels of unconjugated bilirubin are typically associated with conditions affecting the liver or the breakdown of red blood cells, not myocardial infarction.
Correct Answer is C
Explanation
Choice A reason:Shaking the bag is not recommended as it may not adequately mix the solution and could cause emulsion instability.
Choice B reason:Administering the bag as is could be harmful due to the risk of fat embolism or other complications from an unstable emulsion.
Choice C reason:Returning the bag to the pharmacy is the appropriate action to ensure the client receives a properly mixed and safe emulsion.
Choice D reason:Turning the bag upside down one time is not sufficient to mix the emulsion and does not address the potential instability of the solution.
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