A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing interventions might be recommended to help prevent aspiration during eating? Select all that apply. (Select All that Apply.)

Have the patient swallow twice after each bite.

Place the patient in a semi-Fowler position.

Provide clear liquids only until the patient can swallow solid foods.

Check the patient's mouth for pocketing of food.

Encourage the use of a straw for liquids.

Place food on the unaffected side of the patient's mouth.

Answer and Explanation

Correct Answer : A,D,F

A. Have the patient swallow twice after each bite: This can help clear any residual food from the mouth and reduce the risk of aspiration.
B. Place the patient in a semi-Fowler position: This position is not ideal for preventing aspiration. The patient should be in an upright, high Fowler’s position to minimize the risk.
C. Provide clear liquids only until the patient can swallow solid foods: Clear liquids can actually be more difficult to control in the mouth and throat than thicker liquids and may increase the risk of aspiration.
D. Check the patient's mouth for pocketing of food: Ensuring that no food is left in the mouth can help prevent aspiration after the patient has finished eating.
E. Encourage the use of a straw for liquids: Using a straw can increase the risk of aspiration because it delivers liquids quickly and may overwhelm the swallowing mechanism, especially in patients with dysphagia.
F. Place food on the unaffected side of the patient's mouth: This helps ensure that the stronger side of the mouth and throat manages the food, reducing the risk of aspiration.

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Correct Answer is C

Explanation

A. Calcium 9.4 mg/dL: This is within the normal range for calcium (8.5-10.2 mg/dL), so it is not a concern.
B. Sodium 140 mEq/L: This value is within the normal range for sodium (135-145 mEq/L), so it is not a concern.
C. Potassium 2.5 mEq/L: This is below the normal range for potassium (3.5-5.0 mEq/L) and indicates hypokalemia, which is a common side effect of furosemide, a diuretic. Hypokalemia can cause serious cardiac issues and requires prompt attention.
D. Magnesium 1.9 mEq/L: This is within the normal range for magnesium (1.5-2.5 mEq/L), so it is not a concern.

A. Numbness and tingling in the opposite extremity B. Severe. Increasing pain that is not relieved with opioids C. Absence of pain in the affected extremity D. Increased pain in the affected extremity upon ambulation

Correct Answer is B

Explanation

A. Numbness and tingling in the opposite extremity: These symptoms might suggest a neurological issue but are not related to compartment syndrome, which is localized to the affected limb and involves pressure within a muscle compartment.
B. Severe, increasing pain that is not relieved with opioids: This is a hallmark sign of compartment syndrome. The pain is disproportionate to the injury and does not respond to usual pain management, indicating increased pressure within the compartment.
C. Absence of pain in the affected extremity: Absence of pain is not a symptom of compartment syndrome. In fact, severe pain is one of the primary symptoms, along with other signs like swelling and decreased sensation.
D. Increased pain in the affected extremity upon ambulation: While pain with movement can occur with many conditions, in compartment syndrome, the severe pain typically occurs regardless of movement and is related to the pressure within the muscle compartment, not just with ambulation.

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A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing interventions might be recommended to help prevent aspiration during eating? Select all that apply. (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing lab values for a patient taking furosemide. Which of these lab values would concern the nurse?

Correct Answer is C

Explanation

The nurse is caring for a patient with a blunt trauma and tissue injury to the lower extremity. Which signs could develop in a patient with compartment syndrome?

Correct Answer is B

Explanation

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