A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Reposition the client without the use of assistive devices.

Raise the side rails on both sides of the client’s bed during repositioning.

Discuss the client’s preferences for determining a repositioning schedule.

Evaluate the client’s ability to help with repositioning.

Answer and Explanation

The Correct Answer is D

This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.

Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.

The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.

Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.

The nurse should use assistive devices that are appropriate for the client’s condition and weight.

Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.

The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.

The nurse should also involve the client in the care plan and respect their preferences whenever possible.

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Correct Answer is D

Explanation

This is because humidification can help moisten the oral mucosa and reduce the discomfort of xerostomia. Xerostomia is a condition of dry mouth caused by reduced or absent saliva flow, which can occur after radiation therapy to the head and neck area.
Choice A is wrong because rinsing the mouth with an alcohol-based mouthwash can irritate the oral tissues and worsen xerostomia. Alcohol can also dehydrate the mouth and reduce saliva production.
Choice B is wrong because esophageal speech is a method of voice restoration after laryngectomy, not a treatment for xerostomia.
Esophageal speech involves swallowing air into the esophagus and releasing it to create sound.
It has nothing to do with saliva flow or dry mouth.
Choice C is wrong because saltine crackers are dry and hard to swallow without adequate saliva.
They can also scratch the oral mucosa and cause pain or bleeding. Offering the client saltine crackers between meals can aggravate xerostomia and increase the risk of choking.
Normal ranges for saliva flow vary depending on the method of measurement, but generally, a stimulated saliva flow rate of less than 0.7 mL/min or an unstimulated saliva flow rate of less than 0.1 mL/min is considered indicative of xerostomia.

A. Inserts the catheter without applying suction. B. Waits for 2 min between suctions. C. Applies suction for 15 seconds. D. Encourages the client to cough during suctioning.

Correct Answer is C

Explanation

The correct answer is **c. Applies suction for 15 seconds**.

**Choice A rationale:** Inserting the catheter without applying suction is a proper step in the suctioning process. This action does not require intervention by the staff nurse.

**Choice B rationale:** Waiting for 2 minutes between suctions is a standard practice to prevent damage to the trachea and to allow the client to recover from the suctioning process. This action is also appropriate and does not require intervention.

**Choice C rationale:** Applying suction for 15 seconds is too long and can cause damage to the trachea. The recommended duration for suctioning is typically 5-10 seconds. This action requires intervention by the staff nurse to correct the procedure and ensure the client's safety.

**Choice D rationale:** Encouraging the client to cough during suctioning is a proper step to help clear the trachea and promote effective suctioning. This action does not require intervention by the staff nurse.

In summary, the newly licensed nurse's action of applying suction for 15 seconds is the one that requires intervention by the staff nurse to correct the procedure and ensure the client's safety.

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A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

Correct Answer is D

Explanation

A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

Correct Answer is C

Explanation

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