Nokea
A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?
- A. Pulmonary embolism
- B. Diarrhea
- C. Pneumonia
- D. Pressure injury
Correct Answer: C
Rationale: Pneumonia is a primary concern in dysphagia due to aspiration risk, potentially leading to infection.
You may also like to solve these questions
A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?
- A. The nurse administers the feeding through a syringe barrel by gravity.
- B. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
- C. The nurse allows the client to rest in a supine position during feeding.
- D. The nurse irrigates the NG tube with tap water after feeding.
Correct Answer: C
Rationale: Supine position during feeding increases aspiration risk; semi-Fowler's is recommended.
A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
- A. Increased collagen
- B. Increased muscle mass
- C. Decreased serum calcium
- D. Decreased circulation
Correct Answer: D
Rationale: Decreased circulation from immobility reduces tissue oxygenation, increasing pressure injury risk.
A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?
- A. Flush the tube with sterile sodium chloride solution every 2 hr.
- B. Change the feeding bag every 24 hr.
- C. Position the head of the client's bed at 15°.
- D. Check the gastric residual every 8 hr.
Correct Answer: B
Rationale: Changing the feeding bag every 24 hours prevents bacterial growth and infection, a standard practice for continuous feedings.
A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. High blood pressure
- B. Moist skin
- C. Dark-colored urine
- D. Distended neck veins
Correct Answer: C
Rationale: Dark urine indicates dehydration as kidneys concentrate urine to conserve water.
A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?
- A. I will turn my mother on her left side during the feeding.
- B. I will position the head of the bed 45 degrees during the feeding.
- C. I will allow the position my mother finds most comfortable during the feeding.
- D. I will elevate the head of the bed 10 degrees during the feeding.
Correct Answer: B
Rationale: Elevating the bed 45 degrees prevents aspiration and aids digestion during feedings.