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

Heparin is an anticoagulant that prevents the formation of new clots and the extension of existing clots. It is the drug of choice for treating acute pulmonary embolism, which is a life-threatening condition caused by a blood clot that travels to the lungs and blocks a pulmonary artery.

a) Dexamethasone is a corticosteroid that reduces inﬂammation and suppresses immune response. It is not indicated for treating pulmonary embolism, but it may be used for other pulmonary conditions, such as asthma or COPD.
b) Atropine is an anticholinergic that blocks the action of acetylcholine and increases heart rate and cardiac output. It is not indicated for treating pulmonary embolism, but it may be used for bradycardia or asystole.
d) Furosemide is a loop diuretic that increases urine output and reduces ﬂuid volume and blood pressure. It is not indicated for treating pulmonary embolism, but it may be used for heart failure or edema.

A. Performing the procedure independently B. Attending a class given about tracheostomy care C. Verbalizing all steps in the procedure D. Asking appropriate questions about suctioning

Correct Answer is A

Explanation

Performing the procedure independently is the best indicator of the partner's readiness for the client's discharge, as it demonstrates competence and confidence in suctioning. Suctioning is a skill that requires practice and supervision until mastery is achieved. The nurse should observe and evaluate the partner's performance of suctioning and provide feedback and reinforcement as needed.

b) Attending a class given about tracheostomy care is a good action by the partner, but not the best indicator of readiness for the client's discharge. Attending a class can provide information and education about tracheostomy care, but it does not necessarily translate into skill acquisition or application. The nurse should assess the partner's understanding and retention of the information and provide additional teaching or clarification as needed.
c) Verbalizing all steps in the procedure is a good action by the partner, but not the best indicator of readiness for the client's discharge. Verbalizing all steps in the procedure can help the partner remember and follow the correct sequence and technique of suctioning, but it does not necessarily reﬂect actual performance or ability. The nurse should observe and verify that the partner is doing what they are saying and correct any errors or omissions as needed.
d) Asking appropriate questions about suctioning is a good action by the partner, but not the best indicator of readiness for the client's discharge. Asking appropriate questions about suctioning can show interest and involvement in learning and caring for the client, but it does not necessarily indicate competence or confidence in suctioning. The nurse should answer the partner's questions and provide additional resources or referrals as needed.

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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 just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Correct Answer is C

Explanation

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

Correct Answer is A

Explanation

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