A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?
The client tucks his chin while swallowing food.
The client sits upright in bed during meals.
The client pockets food on one side of his mouth.
The client has a cough reflex.
The Correct Answer is C
A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.
B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.
C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.
D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inserting an indwelling urinary catheter is within the scope of practice of an LPN and is an appropriate task to delegate.
B. Measuring abdominal girth involves assessment of ascites progression, which requires the nurse’s judgment and should not be delegated.
C. Assessing and documenting the client’s level of consciousness requires critical nursing judgment and must be performed by the RN.
D. Measuring gastric drainage every 2 hr is an appropriate task for an AP, not specifically requiring an LPN.
Correct Answer is C
Explanation
A. Shingles is not contagious; it is caused by the reactivation of the varicella-zoster virus.
B. HIV is not transmitted through routine patient care; universal precautions should be taken.
C. Tuberculosis is an infectious disease that poses a risk to pregnant individuals, so it's best for the pregnant nurse to avoid exposure.
D. Alcoholic pancreatitis and impetigo are not infectious diseases and do not pose a risk of transmission to the pregnant nurse.
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