A nurse is caring for a client who had a stroke and is having difficulty swallowing. Which of the following referrals should the nurse make for the client?
Physical therapy
Speech therapy
Respiratory therapy
Occupational therapy
The Correct Answer is B
A. Physical therapy: Physical therapists focus on improving mobility, balance, and strength. While important after a stroke, they do not primarily address swallowing difficulties.
B. Speech therapy: Speech-language pathologists assess and treat dysphagia (swallowing disorders) and communication difficulties. Referral to speech therapy ensures the client receives appropriate evaluation and interventions to prevent aspiration and maintain nutrition.
C. Respiratory therapy: Respiratory therapists manage airway and pulmonary function issues. They may assist if complications like aspiration pneumonia occur, but they do not directly treat swallowing difficulties.
D. Occupational therapy: Occupational therapists help with activities of daily living and adaptive strategies for self-care. While they may assist with feeding techniques or positioning, they do not specialize in swallowing assessments or interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "A living will is a document that includes my wishes about health care decisions.": A living will is an advance directive that specifies a client’s preferences for medical treatment in situations where they are unable to communicate.
B. "My partner needs to be present as a witness when I sign a living will.": Witness requirements vary by state, and typically a neutral adult, not necessarily a partner, must witness the signing.
C. "My provider will make my health care decisions if I complete advance directives.": Advance directives are intended to communicate the client’s own wishes, not delegate decision-making solely to the provider. The provider’s role is to follow the client’s documented preferences.
D. "Advance directives outline who inherits my material possessions in the event of my death.": Inheritance is addressed in a will, not advance directives. Advance directives focus exclusively on medical and end-of-life care decisions.
Correct Answer is D
Explanation
Rationale:
A. Obtain filterless IV tubing: Blood transfusions require specialized IV tubing with an in-line filter to remove clots and debris. Using filterless tubing would increase the risk of transfusing particulate matter into the client’s bloodstream.
B. Place the blood in a warmer for 1 hr: Blood should only be warmed if specifically prescribed and done using an approved device immediately before administration. Prolonged warming increases the risk of bacterial growth and hemolysis.
C. Use a 24-gauge IV catheter: Packed RBCs should be administered through a larger-bore catheter (typically 18–20 gauge) to allow adequate flow and prevent hemolysis. A 24-gauge catheter is too small for efficient transfusion.
D. Prime IV tubing with 0.9% sodium chloride: Normal saline is the only compatible solution for priming and administering blood products. It prevents clotting and hemolysis while ensuring that the blood flows freely without interacting with other IV solutions.
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