The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

Instruct the patient to swallow the medication with the head tilted backwards

Place the medication in the backwards in the back of the mouth on the affected side

Evaluate the patient’s ability to swallow

Provide the patient with thickened liquids

Answer and Explanation

The Correct Answer is C

A) Instruct the patient to swallow the medication with the head tilted backwards:
Tilting the head backward while swallowing may worsen the patient's ability to swallow, especially if they are experiencing facial droop and slurred speech. This position could increase the risk of aspiration or choking. A safer approach involves evaluating the patient’s swallowing ability before giving any oral medications.

B) Place the medication in the back of the mouth on the affected side:
While placing the medication on the unaffected side might seem like an alternative to help with swallowing, it is still important to assess the patient's swallowing ability first. If the patient has difficulty swallowing due to neurological deficits, placing the medication on the affected side could increase the risk of aspiration, leading to complications such as pneumonia.

C) Evaluate the patient’s ability to swallow:
Evaluating the patient's ability to swallow is the most important initial action. Facial droop and slurred speech can indicate potential dysphagia or difficulty swallowing, which could lead to aspiration if medications are given orally without further assessment. The nurse must determine if the patient can swallow safely before administering any oral medications, including aspirin, to prevent complications.

D) Provide the patient with thickened liquids:
Thickened liquids may be helpful for patients with known dysphagia, but this approach is not suitable in this case because the first priority is assessing the patient's swallowing ability. Giving thickened liquids without evaluating swallowing could increase the risk of aspiration if the patient is unable to manage liquids safely. An evaluation should precede any interventions like thickening liquids.

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Correct Answer is ["300"]

Explanation

Given:

IV fluids initiated at: 03:30

Infusion rate: 120 mL/hr

To find:

Volume of IV fluids infused by 06:00

Step 1: Calculate the duration of infusion

Time elapsed from 03:30 to 06:00 is 2 hours and 30 minutes, which is equal to 2.5 hours.

Step 2: Calculate the volume of IV fluids infused

Volume = Infusion rate x Time elapsed

Volume = 120 mL/hr x 2.5 hours = 300 mL

A. Obtaining a primary and secondary tubing set B. Ensuring another licensed personnel is available C. Obtaining 0.9% normal saline solution D. Checking ABO and Rh status of the donor and recipient

Correct Answer is B

Explanation

A) Obtaining a primary and secondary tubing set:
The primary tubing is used for the intravenous access, and the secondary tubing is attached for administering the blood product. This ensures that the blood transfusion will be delivered effectively, and it is a standard practice to use proper IV tubing for blood products to avoid contamination or complications.

B) Ensuring another licensed personnel is available:
. While it is required that two licensed healthcare professionals verify the blood product before starting the transfusion, this action itself is not contraindicated, it is required. Both individuals should independently check the patient's identification, blood type, and the matching of the blood product before administration. Therefore, the answer to the question should not be about ensuring availability of licensed personnel as this is actually a required safety measure, not contraindicated. The actual contraindications involve actions like using inappropriate fluids for transfusion or mismatching blood.

C) Obtaining 0.9% normal saline solution:
This is appropriate and necessary when preparing for a blood transfusion. Normal saline (0.9%) is the only compatible solution that should be used to flush the IV line before and after the transfusion or to prime the blood tubing. Other solutions, such as lactated Ringer's, can cause clotting when mixed with blood, making saline the only appropriate choice.

D) Checking ABO and Rh status of the donor and recipient:
This is essential and mandatory before administering a blood transfusion. It is critical to ensure that the ABO blood group and Rh factor of the donor and recipient are compatible to prevent hemolytic reactions. This compatibility check must be done every time before administering a transfusion, and it is an integral part of ensuring patient safety.

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The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

Correct Answer is ["300"]

Explanation

The nurse is preparing for a blood transfusion. Which of the following would be contraindicated to include in the prep for the procedure?

Correct Answer is B

Explanation

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