NCLEX-RN
Implementation Questions
Extract:
Question 1 of 5
A client who has experienced a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101°F (38.3°C) and an oxygen saturation of 91% (down from 98% previously), is slightly confused, and has noticeable dyspnea. Which action should the nurse take?
Correct Answer: A
Rationale: The client is exhibiting clinical signs and symptoms of aspiration, which include fever, dyspnea, decreased arterial oxygen levels, and confusion. Other symptoms that occur with this complication are difficulty with managing saliva or coughing or choking while eating. Because the client has developed a complication that requires medical intervention, the most appropriate action is to contact the primary health care provider. The remaining options are not related to the management of aspiration.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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