A patient is receiving total parenteral nutrition and has been NPO postoperatively. The physician ordered small amounts of clear liquids today. The nurse's priority is to ensure which criterion is addressed before giving the patient anything by mouth?
Select one:
The patient's current weight.
The presence of the swallow reflex.
The patient has an appetite.
Adequate pulse and blood pressure readings.
The Correct Answer is B
A. While weight is important for overall nutritional monitoring, it is not directly related to the safety of resuming oral intake.
B. Before initiating any oral intake, especially in a patient who has been NPO, it is critical to assess for a functioning swallow reflex to prevent aspiration.
C. Appetite does not ensure that the patient can safely swallow or tolerate oral intake.
D. Vital signs are important but do not determine swallowing safety or aspiration risk.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hydrochlorothiazide is a diuretic used to treat hypertension; while it can have side effects, liver toxicity is not a common one.
B. Long-term smoking affects the lungs and cardiovascular system more prominently than the liver.
C. Acetaminophen (especially at or above 4,000 mg/day) is a leading cause of liver toxicity, particularly in overdose or prolonged high-dose use. A dose of 4,500 mg/day exceeds the recommended maximum and increases the risk for liver damage.
D. A high-fiber diet is generally beneficial and not associated with liver toxicity.
Correct Answer is C
Explanation
A. Stomatitis (inflammation of the mouth) can occur with chemotherapy or radiation but is not directly related to thrombocytopenia.
B. This is typically associated with neurologic disorders or electrolyte imbalances, not low platelet counts.
C. Thrombocytopenia is a low platelet count, which impairs the blood’s ability to clot. This puts the patient at high risk for bruising, prolonged bleeding, spontaneous bleeding, and internal hemorrhage.
D. While a headache may occur for various reasons, it is not a hallmark symptom or direct consequence of thrombocytopenia.
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