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:
The client has four new medications is incorrect. While the addition of new medications may require monitoring and adjustment, it does not directly indicate a need for occupational therapy. Medication management is typically addressed by the healthcare provider or pharmacist.
Choice B Reason:
The client has extreme difficulty swallowing is incorrect. This finding suggests dysphagia, which may require intervention from a speech-language pathologist rather than an occupational therapist. Speech-language pathologists specialize in assessing and treating swallowing difficulties.
Choice C Reason:
The client is experiencing dysarthria is incorrect. Dysarthria refers to difficulty in speaking due to weakness or poor coordination of the muscles used for speech. While it may affect communication and daily activities, it is primarily addressed through speech therapy rather than occupational therapy.
Choice D Reason:
The client requires assistance getting dressed is correct. Difficulty with activities of daily living, such as dressing, bathing, and grooming, is within the scope of occupational therapy. Occupational therapists help clients regain independence in activities of daily living through interventions aimed at improving fine motor skills, coordination, and adaptive strategies. Referring the client to an occupational therapist can help address their dressing needs and promote independence in self-care activities.
Correct Answer is ["A","C"]
Explanation
Choice A Reason:
Providing written information to a client regarding palliative care is correct. Advocating for the client's autonomy and right to information by providing written materials about palliative care empowers the client to make informed decisions about their care.
Choice B Reason:
Documenting a client's refusal to take a prescribed medication is incorrect. While documenting a client's refusal is important for accurate medical records, it is not an example of advocacy. Advocacy involves actively supporting the client's rights, preferences, and needs.
Choice C Reason:
Obtaining an interpreter for a client who speaks a different language than the nurse is correct. Advocating for effective communication ensures that the client can fully understand and participate in their care, regardless of language barriers. Obtaining an interpreter facilitates communication and promotes the client's right to understand and be understood.
Choice D Reason:
Initiating IV access on a client who has dementia while he is sleeping is incorrect. This scenario raises ethical concerns as it involves performing a procedure on a client who is unable to provide consent due to being asleep and having dementia. Without explicit consent or a medical emergency necessitating immediate intervention, initiating IV access in this situation may not align with client advocacy principles.
Choice E Reason:
Implementing a client's plan of care based upon nursing goals is incorrect. While implementing a client's plan of care is part of the nurse's role, it is not necessarily an example of advocacy. Advocacy involves actively promoting and safeguarding the client's rights, preferences, and well-being, which may sometimes involve advocating for modifications to the plan of care based on the client's needs and goals.
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