A charge nurse is observing a licensed practical nurse assist a client who has dysphagia while eating. Which of the following actions by the LPN should the charge nurse identify as providing safe care?
Places food on the stronger side of the client’s mouth
Positions the client at a 30 degree angle prior to eating
Instructs the client to hyperextend their neck when swallowing
Has the client sit upright for 20 min following meals
The Correct Answer is A
A. Places food on the stronger side of the client’s mouth: Placing food on the stronger side of the mouth helps the client chew and swallow more effectively and safely. This compensates for weakness on one side, reducing the risk of choking and aspiration.
B. Positions the client at a 30-degree angle prior to eating: A 30-degree angle is insufficient to reduce the risk of aspiration in clients with dysphagia. The client should be positioned in an upright sitting position (90 degrees) to facilitate safer swallowing and reduce the risk of choking or aspirating food.
C. Instructs the client to hyperextend their neck when swallowing: Hyperextending the neck (tilting the head back) can actually increase the risk of aspiration by opening the airway, making it easier for food or liquids to enter the lungs. The client should be encouraged to tuck the chin slightly when swallowing to protect the airway.
D. Has the client sit upright for 20 minutes following meals: While sitting upright after meals is beneficial for preventing reflux and aspiration, 20 minutes is not sufficient. The client should remain upright for at least 30 minutes after meals to further reduce the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. Review the chart for nonrestraint alternatives for agitation:
This action involves assessing the client's history, current condition, and any documented alternatives to restraints for managing agitation. While exploring nonrestraint interventions is important, addressing the immediate issue of inappropriate restraint use should take precedence.
b. Inform the unit manager:
Notifying the unit manager about the incident is important for escalating the situation and involving higher-level management in addressing the inappropriate use of restraints. However, before escalating, the immediate needs of the client should be addressed.
c. Speak with the AP about the incident:
Engaging in a conversation with the assistive personnel (AP) who applied the restraints allows for clarification of the situation, identification of any misunderstandings or training needs regarding restraint use, and immediate removal of the restraints if necessary. However, ensuring the client's safety should be the first priority.
d. Remove the restraints from the client’s wrist:
In situations where restraints are applied without a prescription or appropriate authorization, it is crucial to remove the restraints promptly to prevent potential harm to the client. However, it is essential to address the root cause of the inappropriate use of restraints and ensure that the client receives appropriate care and monitoring following restraint removal.
Correct Answer is A
Explanation
a. "I should encrypt personal health information when sending emails."
This statement indicates an understanding of the importance of protecting confidential information during electronic communication. Encrypting personal health information in emails adds an extra layer of security to prevent unauthorized access.
b. "I can use another nurse’s password as long as I log off after using the computer."
This statement is incorrect and demonstrates a lack of understanding of client confidentiality. Sharing passwords is a violation of security policies and compromises the confidentiality of client information. Each nurse should have their unique login credentials to ensure accountability and traceability.
c. "I should discard personal health information documents in the trash before leaving the unit."
This statement is incorrect. Discarding personal health information in an unsecured manner, such as in the regular trash, can lead to unauthorized access and a breach of confidentiality. Proper disposal methods, such as shredding or using secure disposal containers, should be followed to protect sensitive information.
d. "I can post the client’s vital signs in the client’s room."
This statement is incorrect. Posting client information, including vital signs, in a public area like the client's room violates confidentiality. Personal health information should be shared only with authorized individuals involved in the patient's care and through secure communication methods. Posting such information in a public space compromises the client's privacy.
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