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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Choose orange juice instead of apple juice:
Explanation: Orange juice is a source of potassium, so this choice would not be appropriate for a low potassium diet.
B. Replace sugar with molasses when baking:
Explanation: Molasses is a good alternative to sugar and does not contribute significantly to potassium intake, making it suitable for a low potassium diet.
C. Avoid using salt substitutes when cooking:
Explanation: Salt substitutes often contain potassium chloride, which can increase potassium intake. Therefore, it's advisable to avoid them on a low potassium diet.
D. Eat granola for breakfast:
Explanation: Granola can be a good source of potassium, so it may not be suitable for someone on a low potassium diet.
Correct Answer is C
Explanation
A. Metoprolol 50 mg PO daily:
This is a beta-blocker that helps lower blood pressure and heart rate. While it may be part of managing heart failure, it is not the immediate priority in a client presenting with signs of fluid overload and congestion.
B. Maintain accurate intake and output records:
Monitoring intake and output is important in managing fluid balance.
However, in this situation, the priority is to address the existing fluid overload promptly.
C. Furosemide (Lasix) 40 mg push:
Furosemide is a loop diuretic that promotes the excretion of excess fluid. Administering it "push" implies a more rapid onset of action, making it suitable for addressing acute fluid overload.
D. Encourage fluid intake, more than 2000 mL/day:
In the context of fluid overload, encouraging additional fluid intake is contraindicated. The focus should be on removing excess fluid with diuretic therapy rather than promoting more intake.
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