A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

The client tucks their chin when they swallow.

The client adjusts the head of their bed to 90°.

The client drinks their thickened juice with a straw.

The client takes frequent breaks while eating.

Answer and Explanation

The Correct Answer is C

A. The client tucks their chin when they swallow:
This is a proper swallowing technique. Tucking the chin helps close off the airway during swallowing, reducing the risk of aspiration. It facilitates the safe passage of food or liquids into the esophagus
B. The client adjusts the head of their bed to 90°:
This action is appropriate. Keeping the head of the bed elevated to 30 to 45 degrees is recommended for clients with dysphagia as it helps prevent aspiration during swallowing.
C. The client drinks their thickened juice with a straw:
This action indicates a potential problem. The use of a straw with thickened liquids is generally not recommended for clients with dysphagia. Thickened liquids are used to slow down the flow of the liquid and reduce the risk of aspiration. Drinking thickened juice through a straw may compromise the effectiveness of thickening and increase the risk of aspiration.
D. The client takes frequent breaks while eating:
This action is also appropriate. Clients with dysphagia may need to take breaks between bites to ensure safe and effective swallowing. It allows the client to pace themselves and reduces the risk of aspiration.

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Correct Answer is D

Explanation

A. The nurse's empathy about the client having to self-inject:

While empathy is important for building a therapeutic relationship, the client's motivation to learn is more likely to be influenced by factors directly related to their own needs and perceived benefits.

B. The client seeking family approval by agreeing to a teaching plan:

External factors, such as seeking family approval, may influence a client's willingness to participate in a teaching plan, but they might not be as effective in sustaining motivation over the long term. Intrinsic motivation tends to be more enduring and impactful.

C. The nurse explaining the need for education to the client:

While explaining the need for education is important, the client's motivation may be more influenced by their personal beliefs about the benefits of learning and meeting their own needs rather than an external explanation.

D. The client's belief that his needs will be met through education:

This statement reflects the client's intrinsic motivation, where the client perceives that learning to self-administer daily low-dose heparin injections will meet his needs. Intrinsic motivation is a powerful driver for learning because it comes from within the individual.

A. Place the sterile field at the level of the nurse's hips. B. Pour liquids into containers outside the sterile field. C. Hold bottles of sterile solution with the label in the palm of the hand. D. Open the outermost flap of the sterile kit toward the body.

Correct Answer is C

Explanation

A. Place the sterile field at the level of the nurse's hips:

This is incorrect. The sterile field should be placed at a waist or chest level to maintain its sterility. Placing it at the level of the nurse's hips increases the risk of contamination from airborne particles, clothing, or unsterile surfaces.

B. Pour liquids into containers outside the sterile field:

This is incorrect. Pouring liquids into containers outside the sterile field may lead to contamination. All actions involving sterile items should be performed within the sterile field to maintain its integrity and prevent the introduction of microorganisms.

C. Hold bottles of sterile solution with the label in the palm of the hand:

Hold bottles of sterile solution with the label in the palm of the hand:This is correct. This prevents label from becoming wet and illegible.

D. Open the outermost flap of the sterile kit toward the body:

Open the outermost flap of the sterile kit toward the body:This is incorrect. When opening a sterile kit, the nurse should open the outermost flap first and away from the body. This minimizes the risk of reaching over the sterile field, reducing the chance of accidental contamination.

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A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

Correct Answer is D

Explanation

A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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