An elderly patient has been admitted with a suspected stroke.
The patient has facial paralysis and is unable to move the left side of their body.
Upon entering the room, the nurse observes the patient’s spouse attempting to give the patient a drink of water, but struggling.
What should the nurse’s next course of action be?

Assist the spouse and carefully give the patient small sips of water.

Obtain thickening powder before providing any more fluids.

Ask the spouse to stop and assess the patient’s swallowing reflex.

Give the spouse a straw to help facilitate the patient’s drinking.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Assisting the spouse and carefully giving the patient small sips of water may seem like a compassionate action. However, it could potentially lead to aspiration if the patient’s swallowing reflex is compromised, which is common in stroke patients.

Choice B rationale

While obtaining thickening powder before providing any more fluids can help prevent aspiration in patients with dysphagia, it is not the immediate action the nurse should take. The nurse first needs to assess the patient’s swallowing reflex before deciding on the appropriate intervention.

Choice C rationale

The nurse should ask the spouse to stop and assess the patient’s swallowing reflex. This is the most immediate and appropriate action. Stroke patients often have impaired swallowing reflexes, which can lead to aspiration if not properly managed. By assessing the swallowing reflex, the nurse can determine the best course of action to ensure the patient’s safety.

Choice D rationale

Giving the spouse a straw to help facilitate the patient’s drinking is not the best course of action. Straws can increase the risk of aspiration in patients with impaired swallowing reflexes. The nurse should first assess the patient’s swallowing reflex before deciding on the appropriate intervention.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Administering morphine as prescribed would help to manage the patient’s reported pain.

Choice B rationale

Monitoring the patient’s vital signs is crucial in assessing the patient’s physiological response to the fall and ensuring stability.

Choice C rationale

Applying a cold pack to the affected area can help to reduce swelling and alleviate pain.

Choice D rationale

Arranging for an X-ray of the left shoulder would help to identify any potential fractures or other injuries resulting from the fall.

A. Print the electronic medical record (EMR) from the backup server. B. Wait for notification that the system has been rebooted. C. Identify information as a late entry in the record. D. Notify the information services department of the situation.

Correct Answer is D

Explanation

Choice A rationale

Printing the electronic medical record (EMR) from the backup server may not be the most immediate action required. While having a backup of the EMR is important, it does not address the immediate issue of the system failure.

Choice B rationale

Waiting for notification that the system has been rebooted is a passive approach and may not be the most effective initial action. It does not address the immediate need to communicate the issue to the appropriate department.

Choice C rationale

Identifying information as a late entry in the record is a documentation practice that is used when charting is not completed in a timely manner. However, this action does not address the immediate issue of the system failure.

Choice D rationale

Notifying the information services department of the situation is the correct action. This allows the appropriate department to begin troubleshooting and resolving the issue. In the event of a system failure, the first step should be to report the issue so that it can be addressed as quickly as possible.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

After a scheduled downtime, the computer documentation system fails to restart.What should be the nurse’s initial action?

Correct Answer is D

Explanation

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection.What foods should the nurse encourage this client to eat?

The nurse is working on an infectious disease unit.Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

A patient with metastatic cancer who was taking hydromorphone orally at home is now receiving the medication intravenously while in the hospital.To evaluate if the patient is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.Which intervention is most important for the nurse to include in the plan of care?

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.Which action should the nurse take next?

A patient with a history of celiac disease has recently been diagnosed with multiple sclerosis.The nurse is preparing to discharge the patient.What is the most important instruction for the nurse to include in the discharge teaching plan?