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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Free Nursing Study Resources

Correct Answer is D

Explanation

A) "Be sure to bend at the hip, not the knee, to pick up items."
After hip replacement surgery, patients are instructed to avoid bending at the hip beyond 90 degrees, as this can dislocate the newly replaced hip. The correct guidance would be to avoid bending at the hip and instead bend at the knee when picking up items, ensuring the hip joint stays in a safe position.

B) "Internally rotating your leg is okay, but do not externally rotate it."
Internal rotation of the hip joint should also be avoided post-surgery, as it can increase the risk of dislocation. The correct teaching is to prevent both internal and external rotation of the hip to ensure the joint remains stable. Patients should be instructed to avoid twisting motions that can compromise the surgical repair.

C) "If we need to help you roll in bed, we will roll you towards the operative side."
This can place undue pressure on the newly replaced hip, potentially leading to dislocation or injury. The operative side should be kept stable and protected, so it is safer to roll the patient onto the non-operative side if necessary.

D) "You should keep your knees apart using a wedge or pillow."
It is essential to keep the knees apart, typically using a wedge or pillow between the legs. This prevents the hip from adducting (moving toward the midline) and reducing the risk of dislocation. Maintaining this position ensures the hip remains in a safe, stable alignment during the healing process.

Correct Answer is ["8"]

Explanation

Given:

Total volume to infuse: 150 mL

Infusion time: 3 hours

Drop factor of tubing: 10 gtt/mL

To find:

Drip rate (gtt/min)

Step 1: Convert infusion time to minutes

3 hours x 60 minutes/hour = 180 minutes

Step 2: Calculate the total number of drops

Total drops = Total volume x Drop factor

Total drops = 150 mL x 10 gtt/mL = 1500 gtt

Step 3: Calculate the drip rate

Drip rate = Total drops / Infusion time in minutes

Drip rate = 1500 gtt / 180 minutes = 8.33 gtt/min

Step 4: Round to the nearest whole number

Since the question asks for the drip rate rounded to the nearest whole number, we round 8.33 to 8 gtt/min.

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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

Which of the following should be included in patient teaching after hip replacement surgery?

Correct Answer is D

Explanation

Correct Answer is ["8"]

Explanation

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