A 72-year-old patient who has a history of a transient ischemic ...

[stevenposner]

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, I don't need the aspirin today. I don't have a fever.
 
  Which action should the nurse take?
  a. Document that the aspirin was refused by the patient.
  b. Tell the patient that the aspirin is used to prevent a fever.
  c. Explain that the aspirin is ordered to decrease stroke risk.
  d. Call the health care provider to clarify the medication order.

Question 2

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then
 
  a. order a varied pureed diet.
  b. assess the patient's appetite.
  c. assist the patient into a chair.
  d. offer the patient a sip of juice.

[blakcmamba]

Answer to Question 1

ANS: C
Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.

Answer to Question 2

ANS: C
The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.