A client who had a cerebral vascular accident (CVA) and is at risk for aspiration is being fed by an unlicensed assistive personnel (UAP). Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Positions the head with the chin tilted slightly downward.

Raises the head of the bed to 60 degrees.

Places food on the unaffected side of the mouth.

Allows 30 minutes of rest before feeding.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect because positioning the head with the chin tilted slightly downward can help prevent aspiration by closing the airway and directing food to the back of the throat.

Choice B Reason: This is incorrect because raising the head of the bed to 60 degrees can help prevent aspiration by using gravity to keep food in the stomach and away from the lungs.

Choice C Reason: This is incorrect because placing food on the unaffected side of the mouth can help prevent aspiration by stimulating the intact nerves and muscles that control swallowing.

Choice D Reason: This is correct because allowing 30 minutes of rest before feeding can increase the risk of aspiration by reducing the client's alertness and coordination. The UAP should feed the client when he or she is awake and responsive.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because contacting the healthcare provider about the frequency of pain medication is a dependent intervention that requires an order from the provider. The nurse should first use independent interventions such as reviewing available prescriptions or providing non-pharmacological measures.

Choice B Reason: This is incorrect because encouraging the client to allow more time for the medication to work can imply that the nurse does not believe or validate the client's report of pain. It also can delay effective pain relief and increase suffering.

Choice C Reason: This is correct because reviewing the medical record for additional pain medication prescriptions can help identify alternative or adjunctive options for pain management, such as breakthrough doses, rescue doses, or non-opioid analgesics.

Choice D Reason: This is incorrect because administering an additional dose of morphine sulfate 0.2 mg intravenously can cause overdose, respiratory depression, or addiction. The nurse should follow the prescribed dosage, route, and interval of administration and monitor for adverse effects.

A. Irrigate the nasogastric tube with water. B. Review the advance directive document. C. Elevate the head of bed 45 degrees. D. Perform oropharyngeal suctioning.

Correct Answer is D

Explanation

The correct answer is: d. Perform oropharyngeal suctioning.

Choice A: Irrigate the nasogastric tube with water

Reason: Irrigating the nasogastric tube with water is not appropriate when a client is choking and vomiting. This action could potentially worsen the situation by introducing more fluid into the stomach, increasing the risk of aspiration.

Choice B: Review the advance directive document

Reason: Reviewing the advance directive document is not an immediate action to take when a client is choking. Advance directives provide guidance on the client’s wishes for medical treatment but do not address acute emergency interventions.

Choice C: Elevate the head of bed 45 degrees

Reason: Elevating the head of the bed to 45 degrees can help reduce the risk of aspiration by using gravity to keep stomach contents down. However, this action alone is not sufficient to address the immediate choking hazard.

Choice D: Perform oropharyngeal suctioning

Reason: Performing oropharyngeal suctioning is the correct action because it directly addresses the choking hazard by clearing the airway of vomit and other obstructions. This is a critical step to ensure the client’s airway is clear and they can breathe properly.

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A client who had a cerebral vascular accident (CVA) and is at risk for aspiration is being fed by an unlicensed assistive personnel (UAP). Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a prescription for morphine sulfate 0.2 mg intravenously every 4 hours as needed for pain reports that pain is a 10 out of 10 on the numeric pain scale one hour after receiving the last administration. Which intervention should the nurse implement?

Correct Answer is C

Explanation

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Correct Answer is D

Explanation

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