Author Question: A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for ... (Read 125 times)

Arii_bell · **on:** Jun 25, 2018

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.)

a. A 24-year-old with a traumatic brain injury
b. A 36-year-old who fractured his left femur
c. A 58-year-old at risk for aspiration following radiation therapy
d. A 66-year-old who is a quadriplegic and has a sacral ulcer
e. An 80-year-old who is aphasic after a cerebral vascular accident

Question 2

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?

a. A 66-year-old client with a barrel chest and clubbed fingernails
b. A 48-year-old client with an oxygen saturation level of 92 at rest
c. A 35-year-old client who has a longer expiratory phase than inspiratory phase
d. A 27-year-old client with a heart rate of 120 beats/min

Moriaki · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A, C, D, E
Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene. Clients at risk include those with altered mental status and level of consciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic) and cough effectively (quadriplegic), and a risk of aspiration (aspiration precautions). The client with a fractured femur is at risk for a pulmonary embolism.

Answer to Question 2

ANS: D
Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92 is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.