An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?

Obtain thickening powder before providing any more fluids.

Assist the spouse and carefully give the client small sips of water.

Ask the spouse to stop and assess the client's swallowing reflex.

Give the spouse a straw to help facilitate the client's drinking.

Answer and Explanation

The Correct Answer is C

Rationale

A. Thickening powder is used to modify the consistency of liquids to prevent aspiration in clients with swallowing difficulties. This option suggests ensuring safety by thickening fluids to reduce the risk of choking or aspiration. However, this does not address the underlying issue.

B. This option involves immediate action to provide hydration under close supervision. It implies that the nurse will closely monitor the client's ability to swallow and assess for signs of aspiration during the process. However, it does not address the underlying risk.

C. This option focuses on assessing the client's ability to swallow before providing more fluids. It acknowledges the potential danger of giving fluids without knowing the client's current swallowing ability, which could lead to aspiration.

D. Providing a straw might seem helpful but could potentially increase the risk of aspiration if the client has swallowing difficulties. It does not address the immediate need for assessing the client's ability to swallow safely.

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Free Nursing Study Resources

Correct Answer is ["18"]

Explanation

(Desired Dose * Volume of IV Bag) / (Concentration of Drug in IV Bag * Time) = Infusion Rate.

For the given prescription, the calculation would be: (900 units/hr * 500 mL) / (25,000 units) = 18 mL/hr.

Therefore, the nurse should program the infusion pump to deliver 18 mL/hr.

A. Soak feet daily in hot water no longer than 10 minutes. B. Include no more than 1-2 alcoholic beverages in diet per day. C. Remember exercise will not affect blood glucose levels. D. Keep any wounds covered with an antibiotic ointment.

Correct Answer is B

Explanation

Rationale

A This statement is incorrect for diabetes management. People with diabetes should avoid soaking their feet in hot water, as it can lead to burns and skin damage, which is particularly risky due to potential nerve damage (neuropathy) and poor circulation common in diabetes.

B. This statement demonstrates good understanding. Alcohol can affect blood sugar levels and should be consumed in moderation by people with diabetes. Limiting intake to 1-2 drinks per day (following healthcare provider's advice) is generally recommended to minimize the impact on blood sugar levels and overall health.

C. Exercise is crucial for managing blood glucose levels in people with diabetes. Physical activity helps muscles use glucose for energy and can lower blood sugar levels. Understanding the importance of regular exercise is key for effective diabetes management.

D. While keeping wounds covered is generally good advice to prevent infection, using antibiotic ointment on every wound is not necessary unless specifically advised by a healthcare professional. Proper wound care, including cleaning with mild soap and water, keeping the wound clean and dry, and seeking medical attention for any signs of infection

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Naxlex Comprehensive Predictor Exams

A client receives a prescription for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["18"]

Explanation

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

Correct Answer is B

Explanation

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms?

Exhibits The nurse starts the albuterol nebulizer as prescribed. Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.