The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

Instruct the patient to swallow the medication with the head tilted backwards

Place the medication in the backwards in the back of the mouth on the affected side

Evaluate the patient’s ability to swallow

Provide the patient with thickened liquids

Answer and Explanation

The Correct Answer is C

A) Instruct the patient to swallow the medication with the head tilted backwards:
Tilting the head backward while swallowing may worsen the patient's ability to swallow, especially if they are experiencing facial droop and slurred speech. This position could increase the risk of aspiration or choking. A safer approach involves evaluating the patient’s swallowing ability before giving any oral medications.

B) Place the medication in the back of the mouth on the affected side:
While placing the medication on the unaffected side might seem like an alternative to help with swallowing, it is still important to assess the patient's swallowing ability first. If the patient has difficulty swallowing due to neurological deficits, placing the medication on the affected side could increase the risk of aspiration, leading to complications such as pneumonia.

C) Evaluate the patient’s ability to swallow:
Evaluating the patient's ability to swallow is the most important initial action. Facial droop and slurred speech can indicate potential dysphagia or difficulty swallowing, which could lead to aspiration if medications are given orally without further assessment. The nurse must determine if the patient can swallow safely before administering any oral medications, including aspirin, to prevent complications.

D) Provide the patient with thickened liquids:
Thickened liquids may be helpful for patients with known dysphagia, but this approach is not suitable in this case because the first priority is assessing the patient's swallowing ability. Giving thickened liquids without evaluating swallowing could increase the risk of aspiration if the patient is unable to manage liquids safely. An evaluation should precede any interventions like thickening liquids.

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Correct Answer is D

Explanation

A. 15-30g oral carbohydrates:
Oral carbohydrates are a first-line treatment for hypoglycemia in a conscious, alert patient who can safely swallow. However, since the patient is unresponsive, administering oral carbohydrates is not an appropriate option. The patient’s inability to swallow safely increases the risk of aspiration, making IV treatment the priority in this case.

B. 10% dextrose continuous IV infusion:
A 10% dextrose IV infusion can be used in the management of hypoglycemia, but in an acute, emergency setting where the patient is unresponsive and their blood glucose is critically low (30 mg/dL), a rapid-acting intervention is needed. A bolus dose of a concentrated solution, such as 50% dextrose, is more appropriate for quickly raising the blood glucose level in this situation, rather than a continuous infusion, which takes longer to achieve an effective increase in glucose.

C. Glucagon PO:
Glucagon is typically used for hypoglycemia in patients who are unconscious or unable to take oral glucose. However, glucagon is typically administered intramuscularly (IM) or subcutaneously (SQ), not orally (PO). Administering glucagon orally is ineffective, as it would not be absorbed by the body in the necessary manner to correct hypoglycemia. Therefore, this option is inappropriate.

D. 50% dextrose in water (50% DW) IV push:
When a patient is unresponsive and their blood glucose level is critically low (30 mg/dL), the priority treatment is an immediate, concentrated source of glucose. Administering 50% dextrose IV push is the most appropriate intervention in this scenario. It provides a rapid and effective increase in blood glucose levels, which is critical for reversing hypoglycemia in an emergency situation. This is the fastest and most direct approach to treating severe hypoglycemia in an unresponsive patient.

A. Have the client use the call light if they need to get up B. Pad the side rails of the client’s bed C. Ensure the lights in the room are as bright as possible at all times D. Avoid over stimulation and excessive activity in the client’s room

Correct Answer is C

Explanation

A. "Have the client use the call light if they need to get up":
This is an appropriate precaution to promote safety for a patient who has seizures. It is important to encourage patients to call for assistance before getting up, especially if they are at risk for seizures. Having the patient use the call light ensures that they do not try to walk or move without supervision, which could lead to falls or injury.

B. "Pad the side rails of the client’s bed":
This is also an appropriate precaution. Padding the side rails of the bed is a common safety measure for patients who are at risk for seizures. The padding helps prevent injury if the patient moves during a seizure. Side rails should be raised during a seizure to prevent the patient from falling out of bed, but the risk of injury from the side rails themselves is minimized with padding.

C. "Ensure the lights in the room are as bright as possible at all times":
This is not an appropriate precaution. Bright lights in the room could potentially cause overstimulation, which may be a trigger for seizures in some patients. In addition, bright lights could contribute to discomfort and anxiety. Instead, the room should be kept at a comfortable, calm lighting level to help reduce stress and minimize the risk of triggering a seizure.

D. "Avoid over stimulation and excessive activity in the client’s room":
This is an appropriate precaution. Avoiding overstimulation is important for patients with seizure disorders. Excessive noise, bright lights, or other sources of stress or agitation could provoke a seizure. A calm, quiet environment helps to promote safety and reduce the risk of a seizure occurring.

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The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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