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:
Reinforcing dietary teaching with a client who has heart disease is incorrect. Dietary teaching typically requires a higher level of assessment and critical thinking, often involving interpretation of lab values, medication interactions, and individualized dietary plans. This task is best suited for a Registered Nurse (RN).
Choice B Reason:
Providing postmortem care for a client who has just died is incorrect. Providing postmortem care involves emotional support, respect for the deceased, and proper handling of the body. This task is within the scope of practice for an RN and may also involve collaboration with other healthcare team members.
Choice C Reason:
Accompanying a client who just had a wound debridement to physical therapy is incorrect. Accompanying a client to physical therapy may involve monitoring the client's condition, providing assistance during the transfer, and communicating with the physical therapist about the client's status. This task typically requires an RN or may be appropriate for an assistive personnel under RN supervision.
Choice D Reason:
Obtaining a urine specimen from an older adult client is correct. Obtaining a urine specimen is a task that falls within the scope of practice for an LPN. It involves performing a routine procedure that requires technical skills but does not involve complex assessment or critical thinking beyond following established protocols.
Correct Answer is D
Explanation
Choice A Reason:
A client who has Guillain-Barré syndrome and a tracheostomy is incorrect. Guillain-Barré syndrome can be a complex condition, especially when accompanied by a tracheostomy. Caring for a client with this condition requires knowledge and experience in managing respiratory and neurological complications. It may not be suitable for a newly licensed nurse who may require more experience to manage such complex care needs.
Choice B Reason:
A client who has a brain tumor and is admitted for chemotherapy is incorrect. Caring for a client with a brain tumor undergoing chemotherapy involves understanding the effects of both the tumor and the treatment on the client's neurological status and overall well-being. It may require advanced assessment skills and knowledge of potential complications. Assigning this client to a newly licensed nurse may not be appropriate without additional support and supervision.
Choice C Reason:
A client who has multiple sclerosis and ataxia is incorrect. Multiple sclerosis (MS) can present with various neurological symptoms, including ataxia, which affects coordination and balance. Managing the care of a client with MS and ataxia may require familiarity with the disease process, symptom management strategies, and potential complications. It may be more suitable for a nurse with some experience in neurological nursing.
Choice D Reason:
A client who sustained a concussion and is being monitored for complications is correct. Caring for a client with a concussion being monitored for complications is typically within the scope of practice for a newly licensed nurse. Monitoring for changes in neurological status, assessing for signs of increased intracranial pressure, and providing supportive care are tasks that can be managed by a newly licensed nurse under appropriate supervision.
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