The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?

Delegate the feeding to the nursing student.

Place the food on the affected side of the mouth.

Keep the television off while feeding the client.

Ensure the client's head of the bed is less than 30 degrees.

Answer and Explanation

The Correct Answer is C

A.   While the nursing student may assist with feeding, the nurse should always assess the client's swallowing ability and provide direct supervision to ensure the client's safety.
B.   Placing food on the affected side of the mouth can increase the risk of aspiration. The food should be placed on the unaffected side of the mouth.
C.   Distractions can impair the client's ability to focus on swallowing and increase the risk of aspiration. A quiet environment can help the client concentrate on eating.
D.   The head of the bed should be elevated to at least 30 degrees during and after feeding to reduce the risk of aspiration.

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Correct Answer is B

Explanation

A. After a radical cystectomy, the client may have a urinary diversion (such as a stoma) and should be vigilant about monitoring urine output. Absence of urine output can indicate a serious issue, and notifying the provider is crucial.
B. This statement indicates a need for further clarification. After a radical cystectomy, clients typically do not resume normal voiding because the bladder is removed. Instead, they may have a urinary diversion or need to learn how to manage their new urinary output. Normal voiding as before surgery is not possible, so this statement reflects a misunderstanding of the procedure's implications.
C. After surgery, particularly abdominal surgery like a radical cystectomy, patients are often advised to take stool softeners to prevent constipation. Straining can increase the risk of complications and affect the surgical site, so this is a valid precaution.
D. Monitoring the surgical site for signs of infection, such as redness, swelling, or discharge, is an essential part of post-operative care. Clients should be educated on how to check their surgical site for any concerning changes.

A. Encourage the use of incentive spirometry B. report 8/10 incisional pain C. Assess popliteal pulses D. Early ambulation

Correct Answer is D

Explanation

A. This option is primarily aimed at promoting lung expansion and preventing atelectasis (collapse of the lung). While it's an important post-operative intervention, it does not directly reduce the risk of embolic events related to venous thromboembolism.
B. Reporting significant pain (8/10) may indicate complications such as infection or improper healing, but it does not directly relate to reducing the risk of embolic events. While managing pain is important for recovery, simply reporting it does not contribute to preventing VTEs.
C. Assessing popliteal pulses is part of a thorough circulatory assessment, but it mainly focuses on blood flow to the lower extremities rather than preventing embolic events. It can help identify existing DVT but does not actively reduce the risk of embolism.
D. This statement is true and is the best choice for decreasing the risk of an embolic event. Early ambulation promotes venous return, improves circulation, and significantly lowers the risk of DVT and pulmonary embolism in post-operative patients. Encouraging patients to get out of bed and move around as soon as they are stable is a key nursing intervention in post-operative care.

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Blood Cell	Normal Ranges
Red blood cells (mature, circulating)	Male: 451-6.01 million/mm3 Female: 4.01-5.51 million/mm3
Hemoglobin	Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-155 g/dL
Hematocrit	42%-52% in males 36% -48% in females
Reticulocytes	0.5% -2.5% of total RBC count
White blood cells (total)	4.5-11.1 10/mm3
Neutrophils	59% Bands 3% Segs-56%
Eosinophils	2.7%
Basophils	0.5%
Lymphocytes	34%
Monocytes	4%


Platelets	150,000-450,000/mm3

The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement, made by a client being discharged to home after a radical cystectomy, indicates a need for further clarification by the nurse? "I will:

Correct Answer is B

Explanation

The nurse is planning care for client who is recovering from a total abdominal hysterectomy for uterine cancer. The nurse would include which intervention to decrease the risk of an embolic event?

Correct Answer is D

Explanation

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