a nurse is caring for a client following a cva and observes the client experiencing severe dysphagia the nurse notifies the provider which of the foll a nurse is caring for a client following a cva and observes the client experiencing severe dysphagia the nurse notifies the provider which of the foll
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1. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

Correct answer: Supplements via nasogastric tube

Rationale: In the scenario of severe dysphagia following a CVA, the client may have difficulty swallowing and require alternative nutritional support. Providing supplements via a nasogastric tube allows for the delivery of essential nutrients directly into the stomach, bypassing the swallowing difficulties. NPO (nothing by mouth) until dysphagia subsides may be too restrictive for the client's nutritional needs. Initiation of total parenteral nutrition is usually reserved for cases where enteral feeding is not possible or contraindicated. A soft residue diet may not be suitable for a client experiencing severe dysphagia.

2. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel. Which of the following statements should the nurse make?

Correct answer: D

Rationale: The correct statement is D: 'An RN evaluates the client's needs to determine which tasks are appropriate to delegate to assistive personnel.' This is an essential step in the delegation process to ensure that tasks are assigned appropriately based on the client's condition and the competencies of the assistive personnel. Option A is incorrect because while the nurse retains accountability for delegation decisions, the AP is responsible for their actions. Option B is incorrect as tasks should be within the AP's scope of practice regardless of training. Option C is incorrect as delegation typically involves assigning tasks from the RN to the AP, not between APs.

3. Nurse Casey is preparing to administer chemotherapy to a client with leukemia. The nurse wears gloves and a gown to administer the medication and to prevent exposure to the agent by which of the following routes?

Correct answer: D

Rationale: Chemotherapeutic agents can be hazardous to healthcare workers if they are exposed to the drugs during preparation or administration. One of the primary risks is inhalation, where small particles or aerosols of the drug can become airborne and be inhaled, potentially causing harm to the nurse. Protective gear such as gloves and a gown, as well as masks or respirators in some cases, helps prevent this type of exposure.

4. A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. What action should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take when administering medications through a nasogastric (NG) tube is to dissolve medications separately and flush the tube with sterile water. This is important to prevent interactions between medications and ensure accurate administration. Option A is incorrect because tap water may not be sterile and could lead to contamination. Option B is incorrect as it increases the risk of drug interactions and may affect the effectiveness of each medication. Option C is incorrect as 60 mL of water before each medication may not be enough to ensure proper medication delivery and prevent interactions.

5. A nurse is assessing a client who has gastroesophageal reflux disease (GERD). Which of the following findings should the nurse expect?

Correct answer: B

Rationale: The correct answer is B: Burning sensation in the chest. A burning sensation in the chest is a classic symptom of gastroesophageal reflux disease (GERD). Abdominal distention (Choice A) is not typically associated with GERD; it is more commonly seen in conditions like bowel obstruction. Constipation (Choice C) is not a hallmark symptom of GERD, as it is more related to gastrointestinal motility issues. Frequent belching (Choice D) can occur with GERD, but it is not as specific or characteristic as the burning sensation in the chest.

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