A charge nurse is assessing the room of a newly admitted client who has dysphagia. Which of the following pieces of equipment should the nurse ensure is available in the client's room?
Bite block
Yankauer suction device
Large-handled utensils
Nasal cannula and oxygen
The Correct Answer is B
A. A bite block is not typically needed for a client with dysphagia, as it is more commonly used in situations where the airway needs to be protected, such as during seizures or certain dental procedures.
B. A Yankauer suction device should be readily available for a client with dysphagia. Dysphagia increases the risk of aspiration, which can lead to choking or pneumonia. A Yankauer suction device allows for oral suctioning to clear secretions or food particles from the mouth and airway to help prevent aspiration and maintain a patent airway.
C. While large-handled utensils may be helpful for clients with limited dexterity or mobility (such as those with arthritis), they are not essential equipment for managing dysphagia.
D. Nasal cannula and oxygen: Oxygen therapy is not a routine intervention for dysphagia unless the client has respiratory complications that require supplemental oxygen. While aspiration can lead to respiratory issues like aspiration pneumonia, a nasal cannula and oxygen are not immediate necessities in the room for a client with dysphagia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Checking the reading after the other nurse leaves the room is incorrect because it does not address the immediate need for accurate data and doesn't ensure that the initial readings were correct. It's important to act promptly to verify the accuracy of the readings to ensure patient safety.
Choice B Reason:
Documenting a pulse deficit of 16 beats per minute is incorrect. While there seems to be a difference of 16 beats per minute between the apical and radial pulses, it's essential to confirm this discrepancy with further assessment rather than immediately documenting it. Documentation should be based on accurate and verified data.
Choice C Reason:
Report the results of the deficit to the healthcare provider is incorrect. Reporting the results to the healthcare provider without confirming the accuracy of the initial readings may lead to unnecessary alarm or inappropriate interventions. It's important to ensure the data is reliable before escalating to the healthcare provider.
Choice D Reason:
Repeating the assessment to obtain another reading is correct because it allows the nurses to confirm the accuracy of the initial readings and ensure that there is indeed a pulse deficit. This action promotes patient safety by obtaining reliable data for appropriate intervention if needed. It's crucial to rule out any errors or discrepancies in the initial readings before taking further action or reporting to the healthcare provider.

Correct Answer is D
Explanation
Choice A Reason:
Laboratory test results is incorrect. While laboratory test results may be relevant to the client's care, they are not typically included in discharge documentation unless there are specific instructions or follow-up related to these results. Generally, the focus of discharge documentation is on providing instructions and information necessary for the client's continued care at home.
Choice B Reason:
Acuity level of client care is incorrect. The acuity level of client care may be important for internal communication within the healthcare facility, but it is not typically included in discharge documentation to be provided to the client for home care.
Choice C Reason:
Do-not-resuscitate status is incorrect. While this information is critical for the client's medical care, it may already be documented in the client's medical records. It's important to ensure that the client's wishes regarding resuscitation are documented and communicated as appropriate, but it may not be included in the discharge documentation provided directly to the client.
Choice D Reason:
Reconciled medications is correct. Reconciling medications ensures that the client has an accurate and up-to-date list of all medications they should be taking, including any changes made during their hospital stay. This information is crucial for the client's continued care at home and helps prevent medication errors. It's typically included in the discharge instructions to ensure the client understands their medication regimen upon returning home.
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