The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up on this assessment finding?
Obtain a sputum sample.
Inspect the client’s tongue and mouth.
Perform a swallowing assessment.
Assess the client’s nutritional status.
The Correct Answer is C
A. Obtain a sputum sample:
This option is more relevant when the client is experiencing cough with sputum production, which might suggest respiratory issues. However, in the context of coughing after eating or drinking, the primary concern is likely related to the swallowing process rather than respiratory conditions.
B. Inspect the client’s tongue and mouth:
While inspecting the tongue and mouth is a good practice for assessing oral health, it may not directly address the issue of coughing after eating or drinking, which is more indicative of potential swallowing difficulties.
C. Perform a swallowing assessment:
This is the most appropriate option for the given scenario. A swallowing assessment helps identify any abnormalities or difficulties in the swallowing process, which could contribute to the client's coughing after eating or drinking.
D. Assess the client’s nutritional status:
While assessing nutritional status is important for overall health, it may not directly address the immediate concern of coughing after eating or drinking. Nutritional status assessment is a broader aspect of care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Standard precautions:
Standard precautions are the basic level of infection control and should be used for all patient care. These precautions include practices like hand hygiene, the use of personal protective equipment (PPE), and safe injection practices.
B. Airborne precautions:
These precautions are used to prevent the transmission of infectious agents that are spread through the air. In the case of tuberculosis (TB), which is caused by Mycobacterium tuberculosis, airborne precautions are necessary to reduce the risk of airborne transmission.
C. Contact precautions:
Contact precautions are used for patients with known or suspected infections that can be transmitted by direct or indirect contact. Examples include Clostridium difficile infection and multidrug-resistant organisms. These precautions involve the use of PPE and may include patient placement in a private room.
D. Droplet precautions:
Droplet precautions are used when a patient is known or suspected to be infected with pathogens that are transmitted by respiratory droplets. Examples include influenza and certain types of bacterial meningitis. These precautions include placing the patient in a private room and using PPE.
Correct Answer is D
Explanation
A. Monitor daily weights and urine output.
Monitoring daily weights and urine output is an important aspect of managing heart failure or other cardiac conditions. However, in the context of a client with chest pain, ST elevation, and elevated cardiac enzymes (indicating a myocardial infarction), the immediate focus is on addressing the acute event and reducing myocardial oxygen demand.
B. Administer TPA to prevent further damage as a result of a clot.
Tissue plasminogen activator (TPA) is a thrombolytic medication that can be administered to dissolve blood clots in the coronary arteries during a myocardial infarction. However, the administration of TPA has a specific timeframe within which it is most effective. It is crucial to know the elapsed time since the onset of symptoms, and there are specific criteria and contraindications for its use.
C. Provide client education on medications and diet to prevent recurrence.
Client education on medications, lifestyle modifications, and dietary changes is an essential component of long-term management for preventing recurrence of cardiovascular events. However, during the acute phase of a myocardial infarction, the immediate priority is to stabilize the client and address the acute event, with education being a secondary consideration.
D. Reduce pain and myocardial oxygen demand.
During the acute phase of a myocardial infarction, reducing pain and myocardial oxygen demand is the highest priority. This is typically achieved through the administration of medications such as nitroglycerin for vasodilation and opioids for pain relief. Other interventions to optimize oxygen supply and demand, such as supplemental oxygen and reperfusion strategies, may also be considered.
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