A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?

Pneumonia

Pressure injury

Pulmonary embolism

Diarrhea

Answer and Explanation

The Correct Answer is A

A. Pneumonia:
Dysphagia, or difficulty swallowing, can lead to aspiration, where food or liquids enter the airway and lungs instead of the stomach. This can result in pneumonia, an infection of the lungs. Clients with dysphagia are at an increased risk of developing pneumonia due to the aspiration of foreign material into the lungs.

B. Pressure Injury:
Pressure injuries (formerly known as pressure ulcers or bedsores) are caused by prolonged pressure on the skin, usually over bony prominences. Dysphagia itself is not directly related to pressure injuries. These injuries are more commonly associated with immobility and constant pressure on specific areas of the body.

C. Pulmonary Embolism:
Pulmonary embolism is a blockage of the pulmonary artery, usually by a blood clot that travels to the lungs from the legs or other parts of the body. While dysphagia is not directly associated with pulmonary embolism, conditions that cause immobility (such as being bedridden due to dysphagia) can contribute to the risk of developing blood clots.

D. Diarrhea:
Dysphagia is difficulty swallowing and is not directly related to diarrhea. Diarrhea is often associated with gastrointestinal issues, infections, or dietary factors. Monitoring for complications of dysphagia would primarily focus on respiratory issues, such as aspiration pneumonia.

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Correct Answer is C

Explanation

A. Height of the IV pole:
Explanation: The height of the IV pole is important for controlling the rate of the TPN infusion. Adjusting the height can regulate the flow rate.

B. IV insertion site:
Explanation: Monitoring the IV insertion site is crucial to assess for signs of infection, inflammation, or infiltration, which can compromise the effectiveness of TPN.

C. Manifestations of hypoglycemia:
Explanation: TPN often contains glucose, and monitoring for signs of hypoglycemia is important, as abrupt cessation of TPN can lead to low blood glucose levels.

D. The client's oral intake:
Explanation: Since the client is receiving TPN, their oral intake is not the primary source of nutrition. TPN provides essential nutrients intravenously.

A. There are crackles throughout both lung fields. B. The patient's radial pulse is 105 beats/min. C. There is sediment and blood in the patient's urine. D. The blood pressure increases from 88/50 to 122/74 mmHg

Correct Answer is A

Explanation

A.Crackles in the lung fields indicate the presence of fluid in the lungs, which can be a sign of pulmonary edema. This is a serious adverse effect of hypertonic saline infusion (3% saline), as it can lead to fluid overload and respiratory compromise.

B.A slightly elevated heart rate (tachycardia) could occur in response to fluid shifts or the underlying condition, but it is not a specific indicator of an adverse outcome related to hypertonic saline infusion.

C.Sediment or blood in the urine is not a typical adverse outcome associated with hypertonic saline infusion. These findings may indicate a separate issue, such as a urinary tract infection or renal impairment, but they are unrelated to the administration of 3% saline for hyponatremia.

D.A rise in blood pressure may be expected as a result of volume expansion due to fluid administration, and it may even be beneficial if the patient was hypotensive.

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A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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