Which client would the nurse identify as high risk for developing aspiration pneumonia?
A patient with migraines
A patient with leukemia
A patient with asthma
A patient who had a stroke
The Correct Answer is D
D. Patients who have had a stroke are at high risk for aspiration pneumonia due to potential impairment of their swallowing mechanisms and decreased gag reflex, which can occur if the stroke affects the parts of the brain that control these functions. Dysphagia is a common complication of strokes and significantly increases the risk of aspiration.
A. Migraines can cause significant discomfort and sometimes nausea and vomiting, they do not typically impair swallowing or protective airway reflexes. Thus, this patient is not at high risk for aspiration pneumonia.
B. Leukemia itself does not directly increase the risk of aspiration pneumonia. However, if the patient has complications such as severe weakness, altered mental status, or treatment side effects (like mucositis or infections), their risk could be increased, but it is not the primary concern in most leukemia cases.
C. Asthma affects the airways and causes difficulty breathing but does not typically impair swallowing or increase the risk of aspiration. While severe asthma attacks can cause coughing and choking, the primary issue is airway inflammation, not the risk of inhaling food or liquid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
HR: 110 bpm; regular - The heart rate has decreased from 115 bpm and is now regular, suggesting improved cardiac rhythm stability.
RR: 24 breaths/min; rapid, deep - The respiratory rate has decreased from 26 breaths/min, indicating less rapid breathing.
BP: 94/56 mm Hg - While the blood pressure remains relatively low, there is a slight improvement compared to the previous reading.
Glucose 460 mg/dl - The glucose level has decreased from 525 mg/dL and 530 mg/dL in previous readings. While still elevated, this indicates some improvement in hyperglycemia.
Correct Answer is C
Explanation
C. The spacer helps to deliver more medication to the lungs by holding the medication in the chamber, allowing the patient to inhale it more slowly and deeply. This results in better deposition of the medication in the lower airways and reduces the amount of medication that is deposited in the mouth and throat.
A. The primary purpose of the spacer is to increase the amount of medication that reaches the lungs and to reduce the amount deposited in the oropharynx (throat). The spacer helps to ensure that more medication is delivered directly to the airways where it is needed, thereby enhancing the effectiveness of the treatment and reducing side effects.
B. The exhalation slots or vents on a spacer are designed to allow the patient to exhale easily without removing the device from the mouth. The lips should form a tight seal around the mouthpiece of the spacer to ensure effective inhalation, but the exhalation slots should not be intentionally covered.
D. When using a spacer with an MDI, the patient should inhale slowly and deeply. Rapid inhalation can cause the medication to be deposited in the upper airways rather than reaching the lungs. A slow and deep inhalation allows for better medication delivery to the lower airways.
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