A nurse is caring for a client who has had a stroke.
Select the 3 findings that require immediate follow-up.
Drooling
Blood pressure at 1800
Breath sounds at 1000
Hoarse voice
Temperature at 1800
Correct Answer : A,D,E
A. Drooling
Drooling can be concerning due to impaired swallowing and risk of aspiration.
D. Hoarse voice
Hoarseness after swallowing can indicate aspiration, which is a serious complication for stroke patients due to difficulty swallowing.
E. Temperature at 1800
A temperature of 39.6°C (103.3°F) is significantly elevated and suggests a potential infection, which is a serious complication after a stroke
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pacemaker spikes with each T wave indicates a malfunctioning pacemaker.
B. Pacemaker spikes before each P wave would indicate atrial pacing, not ventricular pacing.
C. A ventricular pacemaker stimulates the ventricles to contract, so the pacing spike should precede the QRS complex.
D. Pacemaker spikes after each QRS complex would indicate a malfunctioning pacemaker.
Correct Answer is B
Explanation
A. Cryoprecipitates are primarily used to treat bleeding disorders and conditions such as hemophilia or fibrinogen deficiencies. They are not the first-line treatment for hypovolemic shock, which is generally due to significant blood or fluid loss rather than clotting deficiencies.
B. Packed RBCs are a critical component in the management of hypovolemic shock, especially when the shock is due to significant blood loss. Administering packed RBCs helps restore the blood volume and improve oxygen delivery to tissues. This is particularly important in cases where the patient has lost a large volume of blood due to trauma, surgery, or other causes.
C. Albumin is used to treat hypovolemic shock when there is a need to increase intravascular volume due to fluid loss that results in low oncotic pressure. It is particularly useful in cases of burns, liver disease, or other conditions where fluid leaks into the interstitial space. While it can be used to manage hypovolemic shock, packed RBCs are typically the primary choice for blood loss.
D. Platelets are used to treat bleeding disorders where there is a deficiency in platelet count or function, such as in thrombocytopenia or during chemotherapy. They are not typically used for hypovolemic shock unless the shock is complicated by severe bleeding and platelet dysfunction.
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