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.
The Correct Answer is B
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 correct because 60 degrees is not fully upright and may not provide optimal protection against aspiration. The client should ideally be positioned at 90 degrees during meals if tolerated indicating need for additional teaching
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 incorrect because resting before meals decreases fatigue and improves swallowing ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because a sputum specimen should be placed in a sealed container and labeled with the client's name, date, and time before it is removed from the room. The container should be transported to the laboratory in a plastic bag.
Choice B Reason: This is incorrect because bed linens should be placed in a leak-proof laundry bag and handled with minimal agitation before they are removed from the room. The laundry bag should be closed securely and transported to the laundry facility.
Choice C Reason: This is incorrect because the nurse's stethoscope should be cleaned and disinfected with an alcohol wipe or a germicidal solution before it is removed from the room. The stethoscope should not be shared with other clients or staff.
Choice D Reason: This is correct because paper mask and gown are disposable items that are contaminated with the client's respiratory secretions and body fluids. They should be placed in a designated biohazard bag and disposed of properly before they are removed from the room.
Correct Answer is D
Explanation
Choice A: Have the client hold a pillow over the abdomen to cough and deep breathe is not the most important instruction because it is not related to repositioning. This is a good practice to prevent respiratory complications after surgery, but it can be done at any time.
Choice B: Encourage the client to eat all of the meals that are sent is not the most important instruction because it is not related to repositioning. This is a good practice to promote nutrition and healing after surgery, but it can be done at any time.
Choice C: Offer fruit juice at least twice during both the day and evening shifts is not the most important instruction because it is not related to repositioning. This is a good practice to prevent dehydration and constipation after surgery, but it can be done at any time.
Choice D: Lower the bed prior to helping the client to move up in bed is the most important instruction because it reduces the risk of injury and falls for both the client and the UAP. This is a safety measure that should be done before any repositioning.
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