Practice Question
An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?
Answer Choices:
Correct Answer:
Ask the spouse to stop and assess the client's swallowing reflex.
Rationale:
◾ Clients with stroke and facial paralysis often have dysphagia, putting them at high risk for aspiration.
◾ Assessing the swallowing reflex is a critical safety step before allowing any oral intake.
◾ Unchecked attempts at drinking may lead to aspiration pneumonia, a life-threatening complication.
◾ The nurse's role is to intervene appropriately when family members unknowingly put clients at risk.
◾ Swallow assessments help guide when to involve speech therapy or recommend NPO status.
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This question is from RN HESI Exit~2024 Exam 2 which contains 127 questions.
More Questions from This Exam
While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
Answer Choices:
A. Hematocrit.
B. Neutrophil count.
C. Serum blood glucose (BG) level.
D. Serum albumin.
A client with chronic obstructive pulmonary disease (COPD) smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. The client reports difficulty controlling respiratory distress at home when using the rescue inhaler. Which comment from the client indicates to the nurse that the client is not using the inhaler properly?
Answer Choices:
A. "I always shake the inhaler several times before I start."
B. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away."
C. "I never use the inhaler unless I am feeling really short of breath."
D. "I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best."
E. None
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?
Answer Choices:
A. Encourage client to implement relaxation techniques.
B. Refer client to the social worker for support therapy.
C. Leave the client's room and return later in the day.
D. Explain that insulin is a life-saving drug for the client.
A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.
Answer Choices:
A. A full pitcher of water is on the bedside table.
B. A saline lack is present in the right forearm.
C. A low sodium diet tray was brought to the room.
D. A bedside commode is positioned near the bed.
E. The client is lying in a supine position in bed.
A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?
Answer Choices:
A. Level of consciousness.
B. Respiratory rate.
C. Blood pressure.
D. Pain scale.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI-Exit Exam(s)
- Domain: HESI Exit Exam(s)~2024
- Answer Choices: 4
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