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 C
Explanation
Continuing to monitor the client is the appropriate action for the nurse to take, as a rise in the water seal chamber with client inspiration is a normal and expected finding. The water seal chamber acts as a one-way valve that allows air to exit from the pleural space and prevents air from entering. The water level in this chamber fluctuates with breathing, rising with inspiration and falling with expiration. This indicates that the chest tube system is functioning properly and that there is no air leak.
a) Immediately notifying the provider is not necessary, as a rise in the water seal chamber with client inspiration is not an abnormal or urgent finding. The nurse should only notify the provider if there are signs of complications, such as persistent bubbling in the water seal chamber, which indicates an air leak, or no fluctuation in the water level, which indicates an obstruction or resolution of pneumothorax.
b) Clamping the chest tube near the water seal is not advisable, as it can cause increased pressure in the pleural space and lead to tension pneumothorax. Clamping the chest tube should only be done for a brief period of time and under specific circumstances, such as changing the drainage system, assessing for an air leak, or preparing for chest tube removal.
d) Repositioning the client toward the left side is not helpful, as it does not affect the water level in the water seal chamber. The nurse should position the client according to their comfort and condition, and avoid placing them flat or on their affected side, as this can impair drainage and ventilation.
Correct Answer is C
Explanation
Agitation is a sign of hypoxemia, as the brain is deprived of oxygen and becomes irritable and restless.
The other options are not correct because:
- Nausea is not a specific manifestation of hypoxemia, as it can have many other causes such as medication side effects, gastrointestinal disorders, or anxiety.
- Dysphagia is difficulty swallowing, which is not related to hypoxemia or asthma. It can be caused by neurological, muscular, or structural problems in the throat or esophagus.
- Hypotension is low blood pressure, which is not a typical manifestation of hypoxemia or asthma. It can be caused by dehydration, blood loss, shock, or heart failure.
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