A nurse is assisting with the care of a client who had a stroke.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
- Mucous membranes pink, skin warm and dry.
- Coughing and clearing throat when eating.
- Voice hoarse after swallowing.
- Temperature 38 °C (100.4 °F)
- Bilateral breath sounds with wheezing heard in upper lobes.
- Oxygen saturation 88% on room air
Mucous membranes pink, skin warm and dry.
Coughing and clearing throat when eating.
Voice hoarse after swallowing.
Temperature 38 °C (100.4 °F)
Bilateral breath sounds with wheezing heard in upper lobes.
Oxygen saturation 88% on room air
The Correct Answer is ["B","C","D","E","F"]
- Mucous membranes pink, skin warm and dry.
- Coughing and clearing throat when eating.
- Voice hoarse after swallowing.
- Temperature 38 °C (100.4 °F)
- Bilateral breath sounds with wheezing heard in upper lobes.
- Oxygen saturation 88% on room air
Rationale
Coughing and clearing throat when eating: This indicates potential dysphagia (difficulty swallowing), which increases the risk of aspiration pneumonia—a serious complication post-stroke.
Voice hoarse after swallowing: Hoarseness or voice changes can also signal impaired swallowing or aspiration risk, necessitating evaluation by a speech therapist or further swallowing studies.
Temperature 38.5°C (101.3°F): An elevated temperature may suggest infection (e.g., aspiration pneumonia or another complication) and warrants further investigation, particularly in a post-stroke client.
Bilateral breath sounds with wheezing heard in upper lobes: Wheezing could indicate an airway obstruction, aspiration, or developing respiratory compromise, which is critical in this population.
Oxygen saturation 88% on room air: Hypoxemia is a critical finding requiring immediate intervention, such as supplemental oxygen and investigation into the underlying cause (e.g., aspiration, infection, or pulmonary embolism).
Mucous membranes pink, skin warm and dry: These findings are within normal limits and do not indicate a pressing issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The nurse who delegates a task remains accountable for ensuring that it is completed safely and correctly, even though the delegatee performs the task.
B. There are five rights of delegation: the right task, circumstance, person, direction/communication, and supervision/evaluation.
C. While nurse managers may provide general oversight, individual nurses are responsible for delegating tasks during their shift based on client needs and team resources.
D. The delegatee has a responsibility to seek clarification or decline tasks they are not competent to perform, ensuring safety and ethical practice.
Correct Answer is A
Explanation
A. Discard your mask after each use: Masks should be discarded after each use to prevent contamination.
B. Touch the front of your mask while wearing it: The front of the mask should never be touched while wearing it to avoid contamination.
C. Position the mask on your face with the flexible metal piece at the bottom: The flexible metal piece should be at the top of the mask to form a seal over the nose.
D. Remove your mask prior to removing your gloves: Gloves should be removed first to minimize contamination, followed by the mask.
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