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:
Completing an incident report is inappropriate. While completing an incident report is important for documenting any errors or deviations from the standard of care, it should not be the first action taken. Assessing the client's condition takes precedence to ensure their immediate safety and well-being.
Choice B Reason:
Notifying the provider is inappropriate. Notifying the provider may be necessary, but it should not be the first action taken. Initially, the nurse should assess the client's condition to determine if any adverse effects have occurred as a result of the additional medication dose.
Choice C Reason:
Informing the nursing supervisor is inappropriate. Informing the nursing supervisor may be appropriate, especially if further actions or investigations are needed. However, the immediate priority is to assess the client's condition to ensure their safety.
Choice D Reason:
Observing the client's condition is appropriate. The nurse should first assess the client's condition to determine if any adverse effects have occurred due to the additional medication dose. This assessment helps identify any immediate concerns that require intervention. Based on the client's condition, further actions such as notifying the provider or completing an incident report may be warranted. However, observing the client's condition is the initial and most immediate action to take.
Correct Answer is B
Explanation
A. Convey the client's request to the nurse who witnessed the consent.The nurse who witnessed the consent does not have the authority to explain the risks of the procedure. Their role is only to witness that the consent was signed, not to provide information about the procedure.
B. Notify the provider about the client's concerns.The provider who is performing the cardiac catheterization is legally responsible for explaining the risks, benefits, and alternatives of the procedure. If the client expresses concerns or appears to lack understanding just before the procedure, the nurse should notify the provider so they can further explain the risks and clarify any questions.
C. Explain the risks of the procedure to the client.While the nurse can offer general information about the procedure, only the provider who is performing the procedure should explain the specific risks associated with it.
D. Check to see if the medical record indicates the provider explained the procedure to the client. Even if documentation indicates that the provider previously explained the procedure, the client still has the right to have their concerns addressed by the provider just before the procedure.
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