1. The nurse's assessment findings include right-sided weakness, slurred
speech, and dysphagia. The nurse identifies that the client is at high risk for
several problems. Of the client problems addressed on the nursing plan of
care, which is of the highest priority problem?:
Answer:
A) Aspiration.
Rationale:
Aspiration, or the entry of foreign substances such as food or fluids into the lungs,
may cause hypoxia or respiratory distress. Therefore, this is the highest priority in
establishing the client's plan of care.
2. After establishing priorities, the nurse should take which action next in
developing the client's plan of care?:
Answer:
B) Establish outcomes.
Rationale:
The nurse should first complete the assessment, then analyze the assessed data
to identify problems, and then establish outcomes. After the expected outcomes are
established, the nurse plans and implements interventions, which are then
evaluated to determine if the expected outcomes were accomplished.
3. The nurse plans interventions related to the client's dysphagia. To which
member of the inter-professional team should the nurse obtain a referral
order?:
Answer:
Category | HESI EXAM |
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