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 A

Explanation

Choice A Reason: This is correct because this response invites the client to express her feelings and thoughts without imposing any assumptions or judgments. It also conveys empathy and respect for the client's autonomy.

Choice B Reason: This is incorrect because this response makes an inference about the client's emotional state without validating it with her. It also may sound patronizing or pitying, which can hinder rapport.

Choice C Reason: This is incorrect because this response may be perceived as intrusive or prying, especially if the client is not ready or willing to share details about her personal relationship. It also may trigger negative emotions or memories that can worsen her mood.

Choice D Reason: This is incorrect because this response may be seen as superficial or irrelevant, especially if the client did not enjoy her visit or had a conflict with her significant other. It also may imply that the nurse is avoiding or dismissing the client's current feelings.

A. Wait for notification that the system has been rebooted. B. Identify information as late entry in the record. C. Notify information services department of the situation. D. Print electronic medical record (EMR) from backup server.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because waiting for notification that the system has been rebooted can delay the client's care and compromise safety. The nurse should report the problem as soon as possible and use alternative methods of documentation.

Choice B Reason: This is incorrect because identifying information as late entry in the record is a secondary action that should be done after the system is restored. The nurse should prioritize resolving the technical issue and ensuring continuity of care.

Choice C Reason: This is correct because notifying information services department of the situation is the first action that the nurse should take to alert the experts who can troubleshoot and fix the problem. The nurse should also follow the facility's policy and procedure for documenting in a downtime situation.

Choice D Reason: This is incorrect because printing electronic medical record (EMR) from backup server may not be feasible or accessible depending on the extent of the system failure. The nurse should use paper forms or charts as a temporary measure until the system is back online.

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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 female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

Correct Answer is A

Explanation

The nurse is entering prescriptions for lab work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

Correct Answer is C

Explanation

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client's wife has just learned that her husband is terminally ill. She is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

A client reports pain, numbness, and tingling sensations in the lower legs. How should the nurse document this finding?

The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?