A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?

Pneumonia

Pressure injury

Pulmonary embolism

Diarrhea

Answer and Explanation

The Correct Answer is A

A. Pneumonia:
Dysphagia, or difficulty swallowing, can lead to aspiration, where food or liquids enter the airway and lungs instead of the stomach. This can result in pneumonia, an infection of the lungs. Clients with dysphagia are at an increased risk of developing pneumonia due to the aspiration of foreign material into the lungs.

B. Pressure Injury:
Pressure injuries (formerly known as pressure ulcers or bedsores) are caused by prolonged pressure on the skin, usually over bony prominences. Dysphagia itself is not directly related to pressure injuries. These injuries are more commonly associated with immobility and constant pressure on specific areas of the body.

C. Pulmonary Embolism:
Pulmonary embolism is a blockage of the pulmonary artery, usually by a blood clot that travels to the lungs from the legs or other parts of the body. While dysphagia is not directly associated with pulmonary embolism, conditions that cause immobility (such as being bedridden due to dysphagia) can contribute to the risk of developing blood clots.

D. Diarrhea:
Dysphagia is difficulty swallowing and is not directly related to diarrhea. Diarrhea is often associated with gastrointestinal issues, infections, or dietary factors. Monitoring for complications of dysphagia would primarily focus on respiratory issues, such as aspiration pneumonia.

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Correct Answer is C

Explanation

A. "I will allow the position my mother finds most comfortable during the feeding."
This statement does not provide specific guidance on the proper positioning for enteral feedings. It's important to follow recommended positions to prevent complications.

B. "I will turn my mother on her left side during the feeding."
Turning the client on the left side is not a recommended position for enteral feedings. The head of the bed is usually elevated to 30-45 degrees to prevent aspiration.

C. "I will position the head of the bed 45 degrees during the feeding."
This is the correct choice. Elevating the head of the bed to 45 degrees helps prevent aspiration and facilitates proper flow of enteral feedings into the stomach.

D. "I will elevate the head of the bed 10 degrees during the feeding."
While some elevation is better than lying flat, the recommended angle is usually 30-45 degrees to minimize the risk of regurgitation and aspiration.

A. Identify the clients at greatest risk for development of pressure ulcers. B. Turn and position each client every 2 hr. C. Use a barrier cream when performing perineal care. D. Supervise clients to ensure adequate nutritional intake.

Correct Answer is A

Explanation

A. Identify the clients at greatest risk for the development of pressure ulcers.
This option emphasizes the importance of individualized care. By identifying clients at the highest risk for pressure ulcers, healthcare providers can tailor preventive measures to address specific risk factors such as immobility, nutritional deficits, and skin conditions.

B. Turn and position each client every 2 hr.
Regular turning and repositioning are crucial in preventing pressure ulcers, especially in individuals with limited mobility. This helps distribute pressure, reducing the risk of skin breakdown. However, this alone may not be sufficient if other risk factors are not addressed.

C. Use a barrier cream when performing perineal care.
Barrier creams can be helpful in protecting the skin from moisture and friction, especially in areas prone to pressure ulcers. While this is a good practice, it may not be the top priority compared to identifying those at the highest risk.

D. Supervise clients to ensure adequate nutritional intake.
Proper nutrition plays a vital role in maintaining skin integrity. Malnutrition can contribute to the development of pressure ulcers. Monitoring and ensuring adequate nutritional intake are important components of prevention but may not be the initial priority.

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A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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