A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (Select all that apply)
A client who has had radiation therapy for head and neck cancer
A client who has had prolonged diarrhea
A client who has had a cerebrovascular accident
A client who has lactose intolerance
A client who is 4 hr postoperative following a leg amputation with general anesthesia
Correct Answer : A,C,E
These clients have impaired swallowing, gag reflex, or level of consciousness, which increase their risk of aspiration while eating.
The other options are not correct because:
b. A client who has had prolonged diarrhea does not have a direct risk factor for aspiration, as diarrhea affects the lower gastrointestinal tract and not the upper airway or esophagus.
d. A client who has lactose intolerance does not have a risk factor for aspiration, as lactose intolerance causes abdominal cramps, bloating, gas, or diarrhea when consuming dairy products, but does not affect the ability to swallow or protect the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Keeping the drainage system below the level of the client's chest prevents backflow of fluid or air into the
pleural space and maintains negative pressure in the system.
a) Disconnecting the chest tube from the drainage system during transport is dangerous and can cause pneumothorax, infection, or bleeding. The chest tube should remain connected to the drainage system at all times unless ordered by the provider.
b) Emptying the collection chamber prior to transport is unnecessary and can interfere with accurate measurement of drainage. The collection chamber should be emptied only when it is full or at the end of each shift.
c) Clamping the chest tube prior to transferring the client to a wheelchair is contraindicated and can cause tension pneumothorax, as it prevents air from escaping the pleural space. The chest tube should only be clamped for a brief period when changing the drainage system or checking for air leaks, and only with a provider's order.
Correct Answer is A
Explanation
Radiation therapy can cause immunosuppression, which increases the risk of infection. The nurse should monitor the client for signs of infection such as fever, chills, malaise, or purulent drainage.
- Examine the skin for generalized urticaria. This is not a common side effect of radiation therapy, as urticaria is an allergic reaction that causes hives or welts on the skin. Radiation therapy can cause localized skin irritation, erythema, or dryness, but not generalized urticaria.
- Review laboratory test results for low hemoglobin. This is not a direct effect of radiation therapy, as hemoglobin is a component of red blood cells that carries oxygen in the blood. Radiation therapy can cause anemia, which is a low number of red blood cells, but not necessarily low hemoglobin.
- Monitor the mouth for signs of xerostomia. This is not relevant for a client who receives radiation therapy to treat lung cancer, as xerostomia is dry mouth caused by reduced salivary gland function. This can occur in clients who receive radiation therapy to treat head and neck cancer, but not lung cancer.
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