A nurse is caring for a client who had a stroke and has dysphagia. For which of the following complications should the nurse monitor the client?

Aspiration

Gastroesophageal reflux disease

Peptic ulcer disease

Dumping syndrome

Answer and Explanation

The Correct Answer is A

Aspiration is a common complication in patients with dysphagia post-stroke due to impaired swallowing reflexes, leading to food or liquid entering the lungs.

Choice B reason: Gastroesophageal reflux disease could be a concern but is not directly related to dysphagia post-stroke.

Choice C reason: Peptic ulcer disease is not typically a complication of dysphagia post-stroke.

Choice D reason: Dumping syndrome is related to rapid gastric emptying post-meal, not dysphagia post-stroke.

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Correct Answer is B

Explanation

Choice A reason:Labeling the feeding bag with the date and time is important for tracking, but it is not the first action to take. The priority is to ensure that the NG tube is correctly placed and the stomach contents can be aspirated to verify placement before administering the feeding.

Choice B reason:Aspirating the client's stomach contents is the first action the nurse should take. This is to confirm the correct placement of the NG tube to prevent complications such as aspiration pneumonia. It is a critical step before starting any enteral feeding.

Choice C reason: Hanging the feeding bag 30 cm (12 inches) above the client is necessary for gravity feeding, but it comes after verifying the NG tube placement through aspiration of stomach contents.

Choice D reason:Warming the feeding to room temperature is a comfort measure and helps to prevent gastrointestinal discomfort. However, it is not the first action to take. The priority is to check the tube placement.

A. Blood urea nitrogen (BUN) 20 mg/dL B. Serum Osmolality 290 mOsm/kg H2O C. Magnesium 2.0 mEq/L D. Serum creatinine 1.8 mg/dL

Correct Answer is D

Explanation

Choice A reason: A BUN level of 20 mg/dL is within the normal range (7-20 mg/dL) and does not indicate an increased risk of AKI.

Choice B reason: Serum Osmolality of 290 mOsm/kg H2O is within the normal range (275-295 mOsm/kg H2O) and does not suggest an increased risk of AKI.

Choice C reason: A Magnesium level of 2.0 mEq/L is within the normal range (1.7-2.2 mEq/L) and does not indicate an increased risk of AKI.

Choice D reason: An elevated serum creatinine level, such as 1.8 mg/dL, indicates decreased kidney function and is a risk factor for AKI, especially post-MI where the kidneys may be vulnerable due to reduced cardiac output and potential nephrotoxic interventions.

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A nurse is caring for a client who had a stroke and has dysphagia. For which of the following complications should the nurse monitor the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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