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. Positive Trousseau's sign:
A positive Trousseau's sign (spasms of the hand and forearm when a blood pressure cuff is inflated) is a sign of hypocalcemia, not hypermagnesemia. It indicates low calcium levels in the blood, not elevated magnesium levels. Therefore, this is not indicative of hypermagnesemia.

B. Hypertension and headache:
Hypertension and headache are more commonly associated with hypomagnesemia (low magnesium levels), rather than hypermagnesemia. Elevated magnesium levels tend to cause vasodilation, which can lead to hypotension, not hypertension. Therefore, these symptoms are not consistent with hypermagnesemia.

C. Tachycardia and tachypnea:
Tachycardia and tachypnea are often signs of hypomagnesemia as well, where the body compensates for low magnesium by increasing heart rate and breathing rate. Hypermagnesemia, on the other hand, usually causes bradycardia (slowed heart rate) and respiratory depression. So, tachycardia and tachypnea are not indicative of hypermagnesemia.

D. Depressed deep tendon reflexes and lethargy:
This is the correct answer. Hypermagnesemia can lead to depressed deep tendon reflexes (DTRs) and lethargy, as magnesium is a central nervous system depressant. Elevated magnesium levels inhibit neuromuscular function, which can cause symptoms such as diminished reflexes, muscle weakness, and overall lethargy or drowsiness. This combination of findings is a key indicator of hypermagnesemia.

A. Check the identifying information on the unit of blood against the patient’s ID bracelet B. Stay with the patient for 60 minutes after starting the transfusion C. Add the blood transfusion as a secondary line to the existing IV. D. Prime new primary IV tubing with lactated Ringer's Solution to use for the transfusion

Correct Answer is A

Explanation

A) Check the identifying information on the unit of blood against the patient’s ID bracelet:
This is the highest priority to ensure patient safety before beginning a transfusion. The risk of transfusion reactions, including hemolytic reactions due to mismatched blood, makes verifying patient identification critical. The nurse must match the blood product with the patient’s information and confirm that the blood product is correct for the patient. This verification is typically done with a second nurse to ensure safety. If the blood is mismatched, it can lead to severe, potentially life-threatening consequences.

B) Stay with the patient for 60 minutes after starting the transfusion:
While it is important to stay with the patient during the transfusion and monitor for adverse reactions, the highest priority before starting the transfusion is verifying patient and blood product compatibility. After starting the transfusion, staying with the patient for the first 15 minutes is critical for monitoring for early signs of a transfusion reaction, but this action occurs after the blood has been correctly matched and started.

C) Add the blood transfusion as a secondary line to the existing IV:
Ensuring proper identification and blood product matching is more critical than deciding whether to use a secondary IV line. The nurse should verify patient and blood compatibility first and then proceed with setting up the IV line for transfusion.

D) Prime new primary IV tubing with lactated Ringer's solution to use for the transfusion:
Priming IV tubing with lactated Ringer’s solution is incorrect for a blood transfusion. Blood should only be administered with normal saline, as other fluids, including lactated Ringer's solution, can cause clotting or hemolysis when mixed with blood products. This action would not be a safe or appropriate step in preparing for a blood transfusion. The correct solution to prime tubing for blood transfusions is normal saline, and this is secondary to ensuring proper patient identification and blood compatibility.

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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

A nurse is monitoring a client receiving an infusion of IV magnesium sulfate. Which of the following findings would indicate to the nurse that the client isexperiencing hypermagnesemia?

Correct Answer is D

Explanation

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to ensure patient safety?

Correct Answer is A

Explanation

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