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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Intake and output:
Intake and output refer to monitoring the amount of fluids a person consumes (intake) and eliminates (output) through urine, feces, and other means. While tracking fluid intake and output is important, it may not provide a direct indication of excess fluid retention.
B. Pitting pedal edema:
Pitting pedal edema is swelling in the lower extremities, particularly the ankles and feet, that leaves an indentation (pit) when pressure is applied. This can be a sign of fluid retention but may not always be the earliest or most reliable indicator.
C. Crackles in the bases of the lungs:
Crackles or rales in the bases of the lungs can be indicative of pulmonary congestion, which may occur due to fluid accumulation. However, crackles alone may not always be specific to fluid overload and can be present in other respiratory conditions.
D. Daily weights:
Daily weights are a critical and sensitive measure for assessing fluid balance. Sudden weight gain, especially over a short period, can be a strong indicator of fluid retention. Monitoring weight on a daily basis helps to detect changes early, allowing for prompt intervention.
Correct Answer is ["B","C","D","E"]
Explanation
A. Administer antibiotics
Administering antibiotics is not a direct intervention for preventing atelectasis. Antibiotics are typically prescribed to treat bacterial infections, and atelectasis is more related to lung collapse or incomplete lung expansion.
B. Encourage increased oral fluid intake
Adequate hydration is important for maintaining the moisture of respiratory secretions. This helps prevent mucus from becoming thick and sticky, making it easier for the patient to cough and clear the airways.
C. Early mobilization after surgery
Early mobilization, including activities such as getting out of bed and walking, helps improve lung expansion. It promotes better ventilation and prevents areas of the lungs from collapsing, reducing the risk of atelectasis.
D. Frequent turning of the patient
Turning the patient regularly is crucial for preventing pooling of respiratory secretions in dependent areas of the lungs. By changing the patient's position, nurses can facilitate drainage and ventilation throughout the lungs, minimizing the risk of atelectasis.
E. Use of incentive spirometry
Incentive spirometry is a breathing exercise device that encourages the patient to take slow, deep breaths. This helps expand the lungs and prevents atelectasis by maintaining lung volume and promoting alveolar recruitment.
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