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A nurse is assisting with the care of a client who had a stroke

Exhibits

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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Urge incontinence: Caused by an overactive bladder leading to sudden, intense urge to void-not primarily related to spinal injury.

B. Overflow incontinence: Occurs when the bladder cannot empty properly, leading to dribbling; usually related to obstruction or impaired detrusor muscle, not nerve reflex damage.

C. Stress incontinence: Triggered by pressure (e.g., coughing, sneezing), not neurological issues.

D. Reflex incontinence: Occurs due to neurologic impairment (e.g., spinal cord injury), where the bladder empties without warning or urge.

A. Cleanse the labia. B. Don sterile gloves. C. Cleanse the meatus. D. Lubricate the catheter.

Correct Answer is B

Explanation

A. Cleanse the labia: This must be done after donning sterile gloves to maintain asepsis.

B. Don sterile gloves: Sterile technique is required after opening the kit. Gloves must be put on before touching sterile items like swabs or catheters.

C. Cleanse the meatus: This occurs after sterile gloves are worn and before catheter insertion.

D. Lubricate the catheter: Catheter lubrication happens after gloves are on and after cleaning the area.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

Correct Answer is D

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the catheter kit and placing the pad under the patient, which of the following steps should the nurse perform next?

Correct Answer is B

Explanation

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