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 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 ["100"]

Explanation

To calculate the infusion rate, use the formula:

mL/hr = (volume of solution in mL / time of infusion in hr) x 60 min/hr

Plug in the given values:

mL/hr = (50 mL / 0.5 hr) x 60 min/hr

Simplify and solve:

mL/hr = 100 x 60 min/hr

mL/hr = 100 mL/hr

Round to the nearest whole number and add a leading zero if needed:

mL/hr = 100 mL/hr

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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 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

Correct Answer is ["100"]

Explanation

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