A nurse is caring for a patient with a history of stroke who is unable to speak. What is the priority nursing action?

Correct Answer: C

Rationale: The correct answer is C: Reposition the patient to prevent aspiration. Aspiration is a serious risk for stroke patients, especially those with difficulty swallowing. Repositioning the patient can help prevent aspiration pneumonia. Performing a swallowing assessment (choice A) is important but repositioning for safety takes precedence. Physical therapy (choice B) is important but not the priority in this situation. Administering a short-acting beta-agonist (choice D) is not relevant to the immediate safety concern of preventing aspiration.

Correct Answer: D

Rationale: The correct answer is D: Administer IV morphine. In CKD, pain management is crucial due to complications like uremic neuropathy. Morphine is a common analgesic used in CKD patients. Administering diuretics (A) can worsen kidney function. Administering IV fluids (B) may further stress the kidneys. Administering corticosteroids (C) can exacerbate fluid retention and electrolyte imbalances in CKD patients.

Correct Answer: B

Rationale: The correct answer is B: Administer corticosteroids. Blurred vision in a diabetic patient may indicate diabetic retinopathy, which can lead to vision loss. Administering corticosteroids can help reduce inflammation and prevent further damage to the eyes. Monitoring blood glucose levels (choices A and C) is important but not the priority in this case. Administering oral antihypertensive (choice D) is not indicated for blurred vision in a diabetic patient.

Correct Answer: C

Rationale: The correct answer is C) Keep the patient NPO until the gag reflex returns. This intervention is crucial post-bronchoscopy with biopsy to prevent aspiration due to the effects of local anesthesia. Maintaining NPO status ensures that the patient's airway is protected until their ability to swallow safely is confirmed by the return of the gag reflex. Option A, encouraging the patient to drink clear liquids, is incorrect because introducing fluids too soon post-procedure can lead to aspiration. Option B, placing the patient on bed rest for at least 4 hours, is not the immediate priority after a bronchoscopy with biopsy. Option D, maintaining the head of the bed elevated 90 degrees, is important for respiratory support but not the first priority in this scenario. Educationally, understanding the rationale behind post-bronchoscopy care is essential for nurses caring for patients undergoing this procedure. Emphasizing the importance of airway protection, the prevention of aspiration, and the significance of waiting for the return of the gag reflex can help nurses provide safe and effective care in post-bronchoscopy situations.

Correct Answer: A

Rationale: The correct answer is option A: "I will need to buy a water bottle to carry with me." This statement indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx because radiation therapy can lead to dry mouth as a common side effect. Carrying a water bottle helps the patient stay hydrated and manage dry mouth effectively. Option B: "I should not use any lotions on my neck and throat." This statement is incorrect because using water-based lotions or moisturizers on the neck and throat can actually help soothe any skin irritation that may occur due to radiation therapy. Therefore, this statement does not reflect effective teaching for a patient undergoing laryngeal radiation therapy. Option C: "Until the radiation is complete, I may have diarrhea." This statement is unrelated to the side effects of radiation therapy for the larynx. Diarrhea is not a typical side effect of radiation therapy targeting the larynx, so this option is incorrect in this context. Option D: "Alcohol-based mouthwashes will help clean my mouth." This statement is incorrect because alcohol-based mouthwashes can actually exacerbate dry mouth, which is a common side effect of radiation therapy to the larynx. Therefore, recommending alcohol-based mouthwashes would not be considered effective teaching for a patient undergoing this treatment. In an educational context, it is crucial for healthcare providers to provide accurate and relevant information to patients undergoing radiation therapy. Effective patient education helps patients understand the potential side effects of their treatment and how to manage them appropriately. Encouraging patients to stay hydrated and carry a water bottle is a practical and beneficial strategy for managing dry mouth during laryngeal radiation therapy, making option A the most appropriate choice in this scenario.