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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Serum creatinine 3.5 mg/dL is high and indicates the need for further assessment. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. High creatinine levels can indicate kidney damage or impaired renal function.
Choice B reason: Hematocrit 45% is within the normal range (37-47% for women, 40-50% for men), and it does not indicate the need for further assessment. Hematocrit is the percentage of red blood cells in the blood. Low hematocrit levels can indicate anemia, bleeding, or hemolysis.
Choice C reason: Blood urea nitrogen 18 mg/dL is within the normal range (7-20), and it does not indicate the need for further assessment. Blood urea nitrogen is a waste product of protein metabolism that is filtered by the kidneys. High blood urea nitrogen levels can indicate dehydration, kidney damage, or high protein intake.
Choice D reason: Sodium 140 mEq/L is within the normal range (135-145), and it does not indicate the need for further assessment. Sodium is an electrolyte that helps maintain fluid balance, blood pressure, and nerve impulses. Low or high sodium levels can cause confusion, seizures, or coma.
Correct Answer is A
Explanation
Choice A reason: Alternating the first breast that is offered to the baby with each feeding can help ensure equal stimulation and drainage of both breasts, and prevent engorgement, mastitis, or milk supply problems.
Choice B reason: Storing breastmilk in the refrigerator up to 48 hours is not recommended, as it can reduce the quality and quantity of antibodies and nutrients in the milk. The optimal storage time for breastmilk in the refrigerator is up to 24 hours.
Choice C reason: Nursing the baby once every 4 hours is not sufficient, as it can lead to insufficient milk intake, dehydration, weight loss, or jaundice in the baby. The baby should be nursed on demand, or at least every 2 to 3 hours during the day and every 4 hours at night.
Choice D reason: Offering the baby water between feedings is not necessary, as it can interfere with breastfeeding and cause water intoxication or electrolyte imbalance in the baby. Breastmilk provides enough hydration and nutrition for the baby.
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