Practice Question
A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day.
Answer Choices:
Rationale:
Blank 1: Aspiration
🟦The client is showing clear signs of dysphagia, including food “getting stuck in the mouth” and a hoarse or wet vocal quality, which strongly indicates impaired swallowing.
🟦Dysphagia increases the risk that food, fluids, or saliva may enter the airway instead of the esophagus, leading to aspiration.
🟦Aspiration is especially dangerous in clients with neurological deficits, such as mild left-sided weakness, which may indicate a recent cerebrovascular event affecting swallowing coordination.
🟦The change in vital signs from Day 1 to Day 2—particularly increasing heart rate, temperature, and respiratory rate—could signal early aspiration-related inflammation or infection, such as aspiration pneumonia.
🟦Because aspiration poses a risk to airway protection and oxygenation, early identification and preventive measures are critical.
❌ INCORRECT ANSWERS ELABORATED
❌ Blank 1: Sepsis
🟥 Why This Is Incorrect:
🟥Sepsis results from a systemic infection, usually accompanied by fever, tachycardia, hypotension, and significant clinical deterioration.
🟥While the client’s temperature increased slightly, the findings do not indicate a systemic infection—there is no leukocytosis, hypotension, altered mental status, or other hallmark signs of sepsis.
🟥Mild changes in vital signs can be attributed to normal physiologic variation or stress, not sepsis.
🟥The primary concern from the assessment findings is airway protection, not infection spreading throughout the bloodstream.
❌ Blank 1: Tachycardia
🟥 Why This Is Incorrect:
🟥Tachycardia is an isolated symptom, not a risk condition. The question asks for a risk the client faces, not for a description of a vital sign.
🟥A heart rate increase from 78 to 88/min is mild and can reflect normal variation, pain, anxiety, or slight dehydration—not a condition requiring risk labeling.
🟥Tachycardia does not align with the symptoms of dysphagia or aspiration risk.
❌ Blank 2: Prescribed medications
🟥 Why This Is Incorrect:
🟥The client's medications (metoprolol and simvastatin) do not cause dysphagia or lead directly to aspiration risk.
🟥Prescribed medications are irrelevant to the symptoms observed: difficulty swallowing and hoarse voice.
🟥The question requires a clinical finding, not a medication list, to support the risk.
❌ Blank 2: Oxygenation
🟥 Why This Is Incorrect:
🟥The client’s O₂ saturation on Day 1 and Day 2 remained 96–100%, which is normal and does not indicate impaired oxygenation.
🟥No shortness of breath, cyanosis, or respiratory distress was reported.
🟥Dysphagia—not oxygenation—is the clearest evidence pointing toward aspiration risk.
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This question is from PN Fundamentals 2023 Dec 2025 which contains 72 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Fundamentals of Nursing
- Answer Choices: 0