The neurologic assessment of a patient indicates impaired function of the glossopharyngeal (CN IX) and the vagus nerve (CN X). Based on these findings the nurse plans to:
Insert an oral airway and suction as necessary.
Withhold oral fluids or foods.
Speak clearly while facing the client.
Apply artificial tears to protect the cornea.
The Correct Answer is B
A. Inserting an oral airway and suctioning may be indicated for airway management, but the primary concern is the impaired function of the glossopharyngeal and vagus nerves, which affects swallowing and the risk of aspiration.
B. Withholding oral fluids or foods is crucial because impaired function of these cranial nerves increases the risk of aspiration and can lead to choking or pneumonia, making this the priority action.
C. Speaking clearly while facing the client is a good communication practice but does not address the immediate concern of impaired swallowing and risk of aspiration.
D. Applying artificial tears is important for protecting the cornea, but it is not directly related to the functions of CN IX and CN X or the immediate management of swallowing difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Stage IV pancreatic cancer often leads to bile duct obstruction, causing decreased bile flow into the intestines. This results in clay-colored stools due to the absence of bile pigments.
B. Hematuria, or blood in the urine, is not a common symptom of pancreatic cancer, even in advanced stages. It is more associated with conditions affecting the urinary system.
C. Jaundice causes dark, concentrated urine rather than pale, dilute urine due to the accumulation of bilirubin in the bloodstream, which is excreted through the kidneys.
D. Weight loss, rather than weight gain, is a common manifestation in clients with advanced pancreatic cancer due to malabsorption and cachexia.
Correct Answer is ["16"]
Explanation
To calculate the volume to be withdrawn from the vial, we need to follow these steps:
- Convert the client's weight from pounds to kilograms:
- 110 lbs * (1 kg / 2.2 lbs) = 50 kg
- Calculate the total dose of Vancomycin based on the prescribed dosage:
- 20 mg/kg * 50 kg = 1000 mg
- Calculate the volume to be withdrawn from the vial:
- 1000 mg * (8 mL / 500 mg) = 16 mL
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