The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?

Delegate the feeding to the nursing student.

Place the food on the affected side of the mouth.

Keep the television off while feeding the client.

Ensure the client's head of the bed is less than 30 degrees.

Answer and Explanation

The Correct Answer is C

A.   While the nursing student may assist with feeding, the nurse should always assess the client's swallowing ability and provide direct supervision to ensure the client's safety.
B.   Placing food on the affected side of the mouth can increase the risk of aspiration. The food should be placed on the unaffected side of the mouth.
C.   Distractions can impair the client's ability to focus on swallowing and increase the risk of aspiration. A quiet environment can help the client concentrate on eating.
D.   The head of the bed should be elevated to at least 30 degrees during and after feeding to reduce the risk of aspiration.

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Correct Answer is D

Explanation

A. While pain can occur post-operatively and may be a sign of complications, it is not a direct indicator of bleeding. Pain can result from normal healing, surgical trauma, or other complications, but by itself, it does not specifically point to bleeding at the surgical site.
B. An increased blood pressure might not necessarily indicate bleeding. In some cases, blood pressure may increase due to pain, anxiety, or other factors. However, a significant drop in blood pressure would be more indicative of bleeding, especially in conjunction with other symptoms.
C. A decreased white blood cell count (leukopenia) is not typically associated with bleeding at the surgical site. In fact, following surgery, one might expect the white blood cell count to be normal or slightly elevated due to the body’s response to surgery.
D. This finding is indicative of bleeding at the surgical site. Blood on the pillow would suggest that there is active bleeding that has escaped from the surgical site, which is a significant concern that requires immediate assessment and intervention.

A. "Is the 'lump' painful?" B. "Have you had any trouble urinating?" C. "Have you had unprotected sex recently?" D. "Do you have any discharge from your penis?"

Correct Answer is A

Explanation

A. This response is relevant and helps assess the characteristics of the lump. Pain can be an important factor in differentiating between conditions, such as epididymitis, testicular torsion, or tumors. However, while it is a useful question, it may not provide a comprehensive assessment of the situation.
B. This question can be relevant depending on the underlying cause of the lump. Issues with urination may suggest a problem related to the prostate or bladder rather than the testicle itself. While it can help assess urinary tract involvement, it may not directly address the significance of the lump in the testicle.
C. This question is important in the context of sexually transmitted infections (STIs), which can cause scrotal swelling or lumps due to conditions like epididymitis or orchitis. However, it does not directly assess the lump itself, making it less focused on the immediate concern.
D. This question addresses the possibility of an STI and related conditions. While it is relevant, it is not the best immediate question concerning the lump in the testicle. The presence of discharge may not directly correlate with the testicular lump itself.

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ABG Value	Normal Range
PH	7.35-7.45
PaCO2	35-45 mm Hg
HCO3-	22-26 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a post-op thyroidectomy patient for bleeding. Which finding would indicate bleeding at the surgical site?

Correct Answer is D

Explanation

The nurse is caring for a male patient who complains about a small "lump" that he discovered in his right testicle. What would be the best response by the nurse?

Correct Answer is A

Explanation

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