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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.
Choice B rationale
Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.
Choice C rationale
Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.
Choice D rationale
Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.
Correct Answer is ["A","C","F","H"]
Explanation
H.
Choice A rationale
Monitoring the oxygen saturation is an important nursing intervention following the administration of albuterol. Albuterol is a bronchodilator and should improve oxygen saturation by increasing airflow and oxygen delivery.
Choice B rationale
Deep tracheal suctioning is not typically required following the administration of albuterol unless the patient has excessive secretions or difficulty clearing secretions.
Choice C rationale
Discussing potential asthma triggers with the client is an important nursing intervention. Understanding and avoiding triggers can help prevent future asthma exacerbations.
Choice D rationale
Obtaining a sputum culture is not typically required following the administration of albuterol unless there is a suspicion of a respiratory infection.
Choice E rationale
Positive pressure ventilation is not typically required following the administration of albuterol unless the patient is in severe respiratory distress.
Choice F rationale
Allowing the client to take a position of comfort can help improve breathing and should be encouraged.
Choice G rationale
Discussing aggressive respiratory treatment options is not typically required following the administration of albuterol unless the patient’s condition is not improving or worsening.
Choice H rationale
Weaning the supplemental oxygen may be appropriate following the administration of albuterol if the patient’s oxygen saturation has improved.
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