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. "Inhale through the incentive spirometer 10 times with each use."
Explanation: The specific number of breaths can vary, and it's essential to follow the healthcare provider's or manufacturer's instructions. The emphasis is on taking slow, deep breaths rather than a specific count.

B. "Use the incentive spirometer once every 4 hours."
Explanation: The frequency of use may vary based on the healthcare provider's recommendations, the client's condition, and the healthcare setting. It's crucial to follow the individualized plan of care.

C. "Sit up at a 30-degree angle when using the incentive spirometer."
Explanation: This is correct. The client should sit upright to maximize lung expansion while using the incentive spirometer.

D. "Hold your breath for 7 seconds when using the incentive spirometer."
Explanation: The emphasis is on slow, deep inhalation rather than holding the breath for a specific duration. The primary goal is to improve lung function and prevent atelectasis.

A. "I will cover the catheter so he cannot see it." B. "Let me provide more stimulation in his environment." C. "Let's wait until tonight to see if he continues this behavior." D. "I will call the doctor and get the prescription."

Correct Answer is D

Explanation

A. "I will cover the catheter so he cannot see it."
Explanation: This statement suggests attempting to hide the feeding tube from the client. However, addressing the issue of attempting to remove the feeding tube requires a more comprehensive approach, and simply covering the catheter may not address the root cause.

B. "Let me provide more stimulation in his environment."
Explanation: This statement suggests increasing environmental stimulation. While environmental interventions can be considered, it's important to address the specific behavior and assess whether increased stimulation is an appropriate and effective intervention. It may not directly address the issue of attempting to remove the feeding tube.

C. "Let's wait until tonight to see if he continues this behavior."
Explanation: This statement suggests a passive approach of waiting to see if the behavior persists. However, if a client is attempting to remove a feeding tube, it's important to address the issue promptly to prevent potential harm or complications. Waiting may not be the most proactive approach in this situation.

D. "I will call the doctor and get the prescription."
Explanation: This is the most appropriate choice. Applying restraints requires a healthcare provider's order. The nurse should communicate with the doctor to discuss the client's behavior, assess the need for restraints, and obtain the necessary prescription if deemed appropriate. This ensures a lawful and ethical approach to using restraints.

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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

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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