An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?

Obtain thickening powder before providing any more fluids.

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

Ask the spouse to stop and assess the client's swallowing reflex.

Give the spouse a straw to help facilitate the client's drinking.

Answer and Explanation

The Correct Answer is C

Rationale

A. Thickening powder is used to modify the consistency of liquids to prevent aspiration in clients with swallowing difficulties. This option suggests ensuring safety by thickening fluids to reduce the risk of choking or aspiration. However, this does not address the underlying issue.

B. This option involves immediate action to provide hydration under close supervision. It implies that the nurse will closely monitor the client's ability to swallow and assess for signs of aspiration during the process. However, it does not address the underlying risk.

C. This option focuses on assessing the client's ability to swallow before providing more fluids. It acknowledges the potential danger of giving fluids without knowing the client's current swallowing ability, which could lead to aspiration.

D. Providing a straw might seem helpful but could potentially increase the risk of aspiration if the client has swallowing difficulties. It does not address the immediate need for assessing the client's ability to swallow safely.

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Correct Answer is D

Explanation

Rationale

A. The complement system is part of the immune response and can be activated in various conditions, including sepsis. However, activation of complement pathways does not directly cause DIC. Instead, in septic shock, the release of pro-inflammatory cytokines and tissue factor can trigger systemic coagulation activation, leading to DIC.

B. Inhibition of red blood cell production, such as in conditions like aplastic anemia or certain types of bone marrow disorders, does not directly cause DIC. DIC is primarily a disorder of excessive activation of clotting factors in response to underlying conditions like sepsis, trauma, or cancer.

C. Production of extra platelets, or thrombocytosis, is not the cause of DIC. Thrombocytosis can occur in response to various conditions, but DIC involves consumption of platelets due to widespread activation of clotting within the vasculature.

D. DIC is characterized by the widespread consumption and depletion of clotting factors and platelets as they are used up in the formation of microthrombi throughout the bloodstream. This depletion leads to an increased risk of bleeding due to insufficient clotting factors remaining to maintain hemostasis.

Correct Answer is ["21"]

Explanation

To calculate the flow rate in gtt/min, you can use the formula: (Volume in mL * Drop factor) / Time in
minutes.

For 1 L of lactated Ringer's IV, which is 1000 mL, to be infused over 12 hours, with an IV administration set that delivers 15 gtt/mL, the calculation would be: (1000 mL * 15 gtt/mL) / (12 hours * 60 minutes/hour).

This simplifies to (15000 gtt) / (720 minutes), which equals approximately 20.83 gtt/min.

Therefore, the nurse should regulate the infusion to 21 gtt/min, rounding to the nearest whole
number.

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Naxlex Comprehensive Predictor Exams

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

Correct Answer is D

Explanation

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["21"]

Explanation

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