A nurse is caring for a client who had a stroke and has manifestations of dysphagia. Which of the following interventions should the nurse take?

Use liquids to clear food from the client's mouth.

Tilt the client's head backwards to facilitate swallowing.

Add a thickening agent to liquids.

Place the client in a semi-Fowler's position.

Answer and Explanation

The Correct Answer is C

Choice A reason: Using liquids to clear food from the client's mouth is not a safe intervention for dysphagia. Liquids can easily enter the airway and cause aspiration, which is the inhalation of food or fluids into the lungs. Aspiration can lead to pneumonia, respiratory distress, and death.

Choice B reason: Tilting the client's head backwards to facilitate swallowing is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it opens the airway and allows food or fluids to flow into it.

Choice C reason: Adding a thickening agent to liquids is a safe and effective intervention for dysphagia. Thickened liquids are easier to swallow and control, as they move more slowly through the mouth and throat. They also reduce the risk of aspiration, as they are less likely to enter the airway.

Choice D reason: Placing the client in a semi-Fowler's position is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it lowers the head and neck and reduces the closure of the airway. A better position for dysphagia is upright or high-Fowler's, which elevates the head and neck and enhances the closure of the airway.

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Correct Answer is B

Explanation

Choice A reason: Feedings should not be accompanied by nonnutritive sucking. Nonnutritive sucking is the act of sucking on a pacifier, finger, or other object without getting any nutrition. Nonnutritive sucking can interfere with the establishment of breastfeeding, cause nipple confusion, and reduce milk supply.

Choice B reason: Feedings should be on demand. On demand feeding means feeding the newborn whenever they show signs of hunger, such as rooting, sucking, or crying. On demand feeding helps the newborn regulate their appetite, meet their nutritional needs, and bond with their caregiver.

Choice C reason: Feedings should not begin within 1 hr after birth. This instruction is applicable for breastfeeding, not bottle feeding. Breastfeeding should begin within 1 hr after birth to initiate milk production, stimulate uterine contractions, and transfer colostrum to the newborn. Bottle feeding can be delayed until the newborn is stable and alert.

Choice D reason: Feedings may not occur in clusters. Cluster feeding means feeding the newborn more frequently and for longer periods of time during certain times of the day or night. Cluster feeding is common in breastfed newborns, especially during growth spurts or developmental leaps. Bottle fed newborns may not exhibit cluster feeding, as they tend to have more consistent and predictable feeding patterns.

A. I do not need a pump to administer my feedings. B. I should administer my feedings over 10 to 20 minutes. C. I can administer my feedings while I sleep at night. D. I should advance the rate of my feedings slowly.

Correct Answer is D

Explanation

Choice A reason: A pump is usually needed to administer intermittent tube feedings, as it can control the flow rate and volume of the formula. A pump can also prevent overfeeding, aspiration, or diarrhea.

Choice B reason: Administering feedings over 10 to 20 minutes is too fast, as it can cause abdominal cramps, nausea, vomiting, or dumping syndrome. Intermittent tube feedings should be administered over 30 to 60 minutes.

Choice C reason: Administering feedings while sleeping at night is not recommended, as it can increase the risk of aspiration, reflux, or infection. Intermittent tube feedings should be administered during waking hours and with the head of the bed elevated at least 30 degrees.

Choice D reason: Advancing the rate of feedings slowly is advisable, as it can help the body adjust to the formula and prevent intolerance or complications. The rate should be increased gradually until the desired goal is reached.

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