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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Increased anteroposterior diameter of the chest, also known as barrel chest, is a common finding in clients who have COPD with emphysema. It is caused by chronic air trapping and hyperinﬂation of the lungs, which results in fattening of the diaphragm and widening of the rib cage.

a) Oxygen saturation level 96% is within the normal range of 95% to 100% and does not indicate hypoxemia or impaired gas exchange. Clients who have COPD with emphysema typically have lower oxygen saturation levels, ranging from 88% to 92%.
b) Respiratory alkalosis is a condition in which the blood pH is elevated due to decreased carbon dioxide levels. It is caused by hyperventilation, which can occur in response to hypoxia, anxiety, or pain. Clients who have COPD with emphysema usually have respiratory acidosis, which is a condition in which the blood pH is lowered due to increased carbon dioxide levels. It is caused by hypoventilation, which results from impaired lung function and airway obstruction.
d) Petechiae on chest are small red or purple spots on the skin caused by bleeding from capillaries. They are not a typical finding in clients who have COPD with emphysema, unless they have severe coughing episodes or coagulation disorders. They can indicate infection, inﬂammation, trauma, or vascular disease.

A. Disconnect the chest tube from the drainage system during transport. B. Empty the collection chamber prior to transport. C. Clamp the chest tube prior to transferring the client to a wheelchair. D. Keep the drainage system below the level of the client's chest at all times.

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.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

Correct Answer is C

Explanation

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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