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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:
The patient should be elevated 45-90° before inserting a nasogastric tube helps prevent aspiration and facilitates tube insertion.
Choice B Reason:
Assisting the client into a fetal position on his side in preparation for a lumbar puncture is a proper positioning technique to facilitate the procedure and minimize discomfort for the client.
Choice C Reason:
Assessing the client's gag reflex following an esophagogastroduodenoscopy (EGD) is standard practice to ensure the client's safety and ability to protect their airway after the procedure.
Choice D Reason:
Maintains the chest tube collection device below the level of the insertion site when ambulating the client is correct. Chest tube management is critical to prevent complications such as air leaks, tension pneumothorax, and tube dislodgement. When ambulating a client with a chest tube, it's essential to keep the collection device below the level of the insertion site to ensure proper drainage and prevent air from entering the pleural space. If the collection device is positioned above the insertion site, it could result in fluid or air backflow into the patient's chest cavity, which can lead to complications.

A. Reinforce the potential consequences of not having this information on record to the nursing staff. B. Remind nurses to obtain this information during the admission process. C. Meet with nursing staff to review the policy regarding advance directives. D. Ask nurses who are caring for clients without this information in the medical record to obtain it.

Correct Answer is D

Explanation

Choice A Reason:
Reinforcing the potential consequences of not having advance directives on record is important, but the immediate priority is to ensure that the missing documentation is obtained.
Choice B Reason:
Reminding nurses to obtain advance directive information during the admission process is a proactive approach to preventing future instances of missing documentation. However, the priority now is to address the current gap in documentation for clients already admitted.
Choice C Reason:
Meeting with nursing staff to review the policy regarding advance directives can provide clarification and reinforcement of expectations, but again, the immediate priority is to address the missing documentation for current clients.
Choice D Reason:
Asking nurses who are caring for clients without this information in the medical record to obtain it. The priority action for the nurse manager is to ensure that advance directives, which are critical documents outlining a patient's wishes regarding medical treatment, are obtained for clients who currently lack documentation. This ensures that patients' preferences and choices regarding their care are respected, especially in critical situations.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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