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. A client is refusing care from assistive personnel of the opposite gender:
This situation involves the client's right to refuse care based on personal preferences or cultural beliefs. While it requires attention and respect for the client's wishes, it may not pose an immediate risk to patient care or staff safety.
b. No transport assistance is available to take a client to physical therapy:
This can be resolved by contacting the transportation department or finding an alternative solution, but it is not a critical issue that requires immediate attention.
c. Two nurses had a heated disagreement about a scheduling issue:
While workplace conflicts should be addressed to promote a positive work environment, a heated disagreement about a scheduling issue may not pose an immediate threat to patient care. However, if the disagreement escalates or affects staff morale, it could impact unit functioning and require intervention.
d. Three staff members have called to say they will be absent:
This situation has the most immediate impact on the overall functioning of the unit. Staffing shortages can affect patient care and safety, so it is crucial to address this issue promptly to ensure adequate coverage and maintain the quality of care.
Correct Answer is C
Explanation
a. Document in the client’s chart that an incident report has been filed:
Documenting that an incident report has been filed is an important step in the process of addressing the client's complaint. It ensures that there is a record of the incident and initiates the appropriate follow-up procedures.
b. Call risk management to interview the client:
In long-term care facilities, risk management departments are responsible for investigating incidents and ensuring that appropriate measures are taken to prevent future occurrences. In this situation, involving risk management may be necessary to conduct a thorough investigation.
c. Contact the nurse manager:
The nurse manager is responsible for overseeing the nursing staff and ensuring that quality care is provided to clients. Contacting the nurse manager allows for immediate notification of the incident and enables them to initiate the appropriate steps to address the situation.
d. Reassure the client that the staff is well trained:
While it's important to provide reassurance to the client, simply reassuring them without taking any further action may not adequately address their concerns or prevent similar incidents from occurring in the future.
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