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 measuring temperature at regular intervals allows the nurse to monitor fever patterns and evaluate the effectiveness of interventions.

Choice B Reason: This is incorrect because assessing for flushed, warm skin regularly is not a reliable indicator of fever. Skin temperature may vary depending on environmental factors and blood flow.

Choice C Reason: This is incorrect because varying sites for temperature measurement may result in inaccurate readings. Different sites have different normal ranges and may be affected by external factors.

Choice D Reason: This is incorrect because documenting the client's circadian rhythms is not relevant to assessing fever patterns. Circadian rhythms are natural fluctuations in body functions that occur over a 24-hour cycle.

A. Massage the injection site to increase absorption. B. Rotate injections between the abdomen and gluteal areas. C. Expel the air in the prefilled syringe prior to injection. D. Inject in abdominal area at least 2 inches from the umbilicus.

Correct Answer is D

Explanation

Choice A Reason: Massaging the injection site can cause bruising and bleeding, and is not recommended for subcutaneous heparin injections.

Choice B Reason: Rotating injections between different body sites can increase the risk of hematoma formation and skin irritation, and is not advised for subcutaneous heparin injections.

Choice C Reason: Expelling the air in the prefilled syringe can result in a loss of medication dose, and is not necessary for subcutaneous heparin injections.

Choice D Reason: Injecting in the abdominal area at least 2 inches from the umbilicus is the correct technique for subcutaneous heparin injections, as it reduces the risk of injury to blood vessels and nerves, and ensures consistent absorption of the medication.

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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 is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct Answer is A

Explanation

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

Correct Answer is D

Explanation

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