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: Massage the injection site to increase absorption is not a correct instruction because it may cause bruising and bleeding. Low-molecular-weight heparin is absorbed quickly without massaging.
Choice B: Rotate injections between the abdomen and gluteal areas is not a correct instruction because it may increase the risk of hematoma and infection. The abdomen is preferred over other sites for low-molecular-weight heparin injections.
Choice C: Expel the air in the prefilled syringe prior to injection is not a correct instruction because it may result in loss of medication and inaccurate dosing. The air bubble in the prefilled syringe should be left intact.
Choice D: Inject in abdominal area at least 2 inches from the umbilicus is a correct instruction because it ensures adequate subcutaneous tissue and avoids major blood vessels and organs.
Correct Answer is A
Explanation
Choice A: Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible.
Choice B: Document the event on the chart is not the next action because it should be done after notifying the healthcare provider and completing an incident report.
Choice C: Complete an incident report is not the next action because it should be done after notifying the healthcare provider and before documenting the event on the chart.
Choice D: Inform the nurse on the next shift is not the next action because it should be done after documenting the event on the chart and during handoff.
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