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","E","F"]
Mucous membranes pink, skin warm and dry: These are normal findings and do not require follow-up.
Coughing and clearing throat when eating: This suggests possible aspiration, especially concerning in post-stroke clients.
Voice hoarse after swallowing: A hoarse voice post-swallow is a red flag for aspiration risk and should be evaluated promptly.
Temperature 38 °C (100.4°F): This is a low-grade fever and not immediately concerning without other symptoms.
Bilateral breath sounds with wheezing heard in upper lobes: New-onset wheezing indicates possible airway inflammation, aspiration pneumonia, or respiratory distress.
Oxygen saturation 88% on room air: An O₂ saturation below 90% indicates hypoxemia, requiring immediate attention and supplemental oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Promote active range-of-motion activities: Although helpful, active walking or aerobic activity is more effective than ROM exercises for bowel stimulation.
B. Add fluid and fiber to the diet: Adequate hydration and dietary fiber soften stool and promote regular bowel movements.
C. Avoid gas-producing foods: This might reduce discomfort but does not treat constipation directly.
D. Request that the provider prescribe a stool softener: Non-pharmacological interventions (like diet changes) are first-line unless ineffective.
Correct Answer is A
Explanation
A. Assist the client to the left Sims' position: This position uses gravity to promote flow into the rectum and colon and allows the enema to follow the natural direction of the colon.
B. Put on sterile gloves: Clean gloves are sufficient for enema administration. This is a clean, not sterile, procedure.
C. Hang the enema container 61 cm (24 in) above the anus: The correct height is no more than 45 cm (18 inches) to prevent rapid flow and discomfort.
D. Insert the tubing about 15 cm (6 in) into the anus: Insertion should be 7.5 to 10 cm (3 to 4 inches) in adults. Inserting 6 inches increases the risk of injury.
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