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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because explaining that alternative treatment options may be helpful can be insensitive and unrealistic, as it may raise false hopes or imply that the husband's condition is not serious.
Choice B Reason: This is correct because encouraging the wife to share her feelings can help her cope with her grief and express her emotions in a supportive environment. The nurse should use active listening and empathic responses.
Choice C Reason: This is incorrect because offering reassurance that she is not alone can be dismissive and invalidating, as it may minimize her feelings or imply that she should not feel lonely.
Choice D Reason: This is incorrect because reminding her that her husband may still live a long time can be dishonest and inappropriate, as it may contradict the medical prognosis or imply that she should not prepare for his death.
Correct Answer is A
Explanation
Choice A reason: This is the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. This indicates that the cuff was not inflated high enough to occlude the arterial blood flow and the initial systolic reading was inaccurate. The nurse should release the air, wait for 15 to 30 seconds, and then reinflate the cuff to 30 mm Hg above the first systolic sound. This will ensure a more accurate measurement of the blood pressure.
Choice B reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Continuing the blood pressure assessment until the last Korotkoff sound is heard will result in a lower systolic reading and a higher diastolic reading than the actual blood pressure of the client. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.
Choice C reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point will not change the fact that the cuff was not inflated high enough to occlude the arterial blood flow. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.
Choice D reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound will cause discomfort and pain to the client and may damage the blood vessels. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.
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