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 A
Explanation
a. Prepare to administer antibiotics to the client.
This is the correct action. Cutaneous anthrax is typically treated with antibiotics such as ciprofloxacin, doxycycline, or amoxicillin. Administering antibiotics promptly is essential to prevent the progression of anthrax infection.
b. Wear an N95 respirator mask while caring for the client.
While respiratory protection is important in certain situations, such as when caring for clients with respiratory infections, cutaneous anthrax is not transmitted through respiratory droplets. Therefore, wearing an N95 respirator mask is not necessary when caring for a client with cutaneous anthrax.
c. Plan to administer an antiviral medication to the client.
Anthrax is caused by a bacterium, not a virus, so antiviral medications would not be effective in treating anthrax infection. Antibiotics are the mainstay of treatment for anthrax.
d. Place a surgical mask on the client during transfer to the unit.
Cutaneous anthrax does not spread from person to person through respiratory droplets, so placing a surgical mask on the client during transfer is not necessary for preventing transmission of the disease.
Correct Answer is D
Explanation
a. A client who is 37 weeks gestation and has an L/S ratio of 2:1:
An L/S (Lecithin/Sphingomyelin) ratio of 2:1 indicates mature fetal lungs, which is a positive indicator. While this client may be nearing term, the presence of mature fetal lungs does not necessarily warrant an interdisciplinary care conference unless there are other complications or high-risk factors present.
b. A client who is 28 weeks gestation and has a negative Coombs's titer:
A negative Coombs's titer suggests that the client does not have antibodies against Rh-positive blood cells, which is a normal finding. At 28 weeks gestation, this client may not require an interdisciplinary care conference unless there are other significant complications or risk factors present.
c. A client who is at 39 weeks gestation and has a negative contraction stress test:
A negative contraction stress test indicates that the fetus is not experiencing distress during uterine contractions, which is a reassuring finding. At 39 weeks gestation, while this client may be nearing term, a negative contraction stress test alone may not warrant an interdisciplinary care conference unless there are other concerning factors present.
d. A client who is at 35 weeks gestation and has a biophysical profile of 6:
A biophysical profile (BPP) of 6 is on the lower end of the scale and may indicate potential fetal compromise or risk. This client may benefit from further evaluation and possibly closer monitoring, which could warrant an interdisciplinary care conference to discuss management and potential interventions.
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