A nurse is planning care for a client who is at risk for aspiration due to a stroke. When assisting the client during mealtime, which of the following actions should the nurse plan to take?

Use a syringe to give the client fluids.

Tilt the client's head forward when swallowing.

Schedule physical therapy directly before mealtime.

Encourage the client to complete the meal within 15 min.

Answer and Explanation

The Correct Answer is B

A.   Using a syringe to give the client fluids is not directly related to preventing aspiration during mealtime.
B.   Tilt the client's head forward when swallowing helps to facilitate the movement of food down the esophagus and reduces the risk of aspiration by preventing food from entering the trachea.
C.   Scheduling physical therapy directly before mealtime may increase the risk of aspiration due to potential fatigue or increased weakness during meal consumption.
D.   Encouraging the client to complete the meal within 15 minutes may lead to rushed eating, increasing the risk of aspiration. It's more important to focus on safe swallowing techniques and taking adequate time to eat slowly.

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Correct Answer is A

Explanation

A. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia, which can lead to symptoms such as increased thirst. Notifying the provider of increased thirst can help monitor for potential electrolyte imbalances.
B. Consuming foods high in potassium can exacerbate hyperkalemia, which is a potential side effect of spironolactone. Clients prescribed spironolactone are typically advised to avoid potassium-rich foods.
C. Using a salt substitute to season foods can increase sodium intake, which may counteract the effects of spironolactone and increase the risk of fluid retention and hypertension.
D. Taking spironolactone at bedtime is not typically recommended. It is usually taken in the morning to avoid disrupting sleep due to increased urination.

A. Urine output 25 mL/hr B. Fatigue C. Firm grip bilaterally D. Weight gain

Correct Answer is C

Explanation

A. Urine output of 25 mL/hr may indicate inadequate renal perfusion or ongoing dehydration, which is not indicative of effective treatment for hypernatremia.
B. Fatigue is a nonspecific finding and does not specifically indicate the effectiveness of treatment for hypernatremia.
C. A firm grip bilaterally suggests adequate hydration and electrolyte balance, which would indicate effective treatment for hypernatremia.
D. Weight gain may occur with fluid retention, which could indicate overhydration rather than effective treatment for hypernatremia.

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A nurse is planning care for a client who is at risk for aspiration due to a stroke. When assisting the client during mealtime, which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is C

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A nurse is planning care for a client who is at risk for aspiration due to a stroke. When assisting the client during mealtime, which of the following actions should the nurse plan to take?