One of the diagnoses formulated for this client who recently experienced a CVA (cerebrovascular accident) is Risk for aspiration, related to neuromuscular dysfunction. Of the following interventions, which includes a rationale?
1. Have suction equipment available at all times.
2. Clear secretions from oral/nasal passageways as needed.
3. Keep client in low-Fowler's position to prevent reflux.
4. Provide frequent assessment for presence of obstructive material in mouth and throat.
Correct Answer: 3
Rationale: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain "why" an intervention would be implemented. This intervention does not explain "why" it is being done.
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Which of the following is considered a non-point source of pollution? 1. Hazardous waste site 2. Animal waste from wildlife 3. Chlorine poured down a well 4. Stagnant water ANS: 2
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