A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day.

Exhibits
Complete the following sentence by using the list of options.

The client is at risk for
_
as evidenced by the client's
_

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Aspiration (Option 1): The client's report of feeling food stuck in their mouth, along with the noted hoarseness, indicates difficulty swallowing (dysphagia), which puts them at risk for aspiration. Aspiration occurs when food or liquid enters the airway instead of the esophagus, which can lead to serious complications, including pneumonia.

Dysphagia (Option 2): The presence of dysphagia, or difficulty swallowing, directly supports the risk for aspiration. If the client is unable to swallow safely, there is an increased likelihood of aspiration occurring during eating or drinking.

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Correct Answer is E,D,A,B,C

Explanation

Begin by preparing the sterile solution (Step E), which will be used for cleaning. Remove the inner cannula (Step D) so it can be cleaned. Clean the cannula inside and outside (Steps A and B) to ensure it is free of mucus and debris. Finally, cleanse the stoma site (Step C) to maintain skin integrity and reduce infection risk.

A. deep tendon reflexes 4+ B. Generalized weakness C. mild leg cramping D. Lungs clear E. Heart rate irregular F. Bowel sounds hyperactive x 4 quadrants

Correct Answer is ["A","B","C","E","F"]

Explanation

Deep Tendon Reflexes 4+: This indicates hyperreflexia, which can be associated with electrolyte imbalances, particularly magnesium deficiency, or central nervous system issues. In this context, the client has a low magnesium level (0.7 mEq/L), which can cause neuromuscular irritability and potentially dangerous complications.

Generalized Weakness and Mild Leg Cramping: While muscle strength is reported as equal, the generalized weakness and cramping suggest possible electrolyte imbalances or neurological issues. The combination with low magnesium levels raises concern for further complications.

Heart Rate Irregular: An irregular heart rate can indicate potential cardiac issues, especially in the context of electrolyte imbalances such as hypomagnesemia and the use of hydrochlorothiazide, which can contribute to electrolyte disturbances.

Bowel Sounds Hyperactive x 4 Quadrants: Although hyperactive bowel sounds can be associated with various conditions, in this case, they may be linked to the client's history of vomiting and possible electrolyte imbalance, warranting follow-up to ensure appropriate management of gastrointestinal symptoms.

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Body system	Findings
Neurological	Alert and oriented to person, place, and time: deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	Lungs clear
Cardiovascular	Heart rate irregular: Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day. Exhibits Complete the following sentence by using the list of options. The client is at risk for___ as evidenced by the client's ___

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is E,D,A,B,C

Explanation

Correct Answer is ["A","B","C","E","F"]

Explanation

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A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day.

Exhibits
Complete the following sentence by using the list of options.

The client is at risk for
_
as evidenced by the client's
_