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 D
Explanation
Choice A reason: Using a washcloth to clean the denture surfaces is not a good practice for denture care because it can damage or scratch the dentures. A washcloth is too rough and abrasive for denture cleaning. A soft-bristled toothbrush or a special denture brush should be used to clean the denture surfaces gently.
Choice B reason: Wiping dentures before storing them in a dry container at night is not a good practice for denture care because it can cause warping or cracking of the dentures. Dentures should be rinsed thoroughly and soaked in water or a denture cleanser solution at night to keep them moist and prevent deformation.
Choice C reason: Flossing dentures as part of daily cleaning is not a necessary practice for denture care because it does not remove plaque or food particles effectively from the dentures. Flossing dentures can also damage or dislodge the artificial teeth or gums. Brushing and rinsing dentures are sufficient for daily cleaning.
Choice D reason: Wrapping gloved fingers with gauze to remove dentures is a good practice for denture care because it can prevent slipping or dropping of the dentures. Gauze provides friction and grip for removing dentures safely and gently. Gloves protect from contamination and infection.
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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