A nurse is caring for a client in an acute care setting.
Complete the following sentence by using the list of options.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The client is at risk for hypostatic pneumonia as evidenced by the client's immobility
Rationale
The combination of paraplegia (which leads to limited mobility) and symptoms such as productive cough, tachycardia, and confusion suggest a respiratory issue, likely hypostatic pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Dark yellow urine and low urine output (25 mL/hr) may indicate dehydration or decreased fluid intake, so a fluid bolus is indicated to promote kidney perfusion.
B. Continuous bladder irrigation is typically indicated if there is concern about urinary tract obstruction or blood clots, not for low urine output alone.
C. Clamping the catheter can further hinder urine output and is not indicated.
D. A urine culture and sensitivity might be necessary if infection is suspected, but the priority is to address hydration first.
Correct Answer is B
Explanation
A. Tucking the chin toward the chest (not lifting the chin) may help improve swallowing by narrowing the airway, making it easier to swallow and reducing the risk of aspiration.
B.This positioning makes it easier for the nurse to observe signs of dysphagia, offer assistance as needed, and maintain better eye contact with the client. It also helps promote a more relaxed and reassuring environment, which can improve the client’s ability to swallow.
C. Talking during feeding can increase the risk of aspiration and compromise safe swallowing.
D. Coughing during feedings should not be discouraged, as it may indicate that the client is attempting to clear the airway and should be monitored carefully.
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