A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?
Alternate the client's liquids and solids during meals.
Elevate the client's head of the bed to 45 degrees during meals.
Instruct the client to tilt their head back while swallowing.
Turn on the client's television during meals.
The Correct Answer is B
Choice A reason: Alternating liquids and solids is not a specific intervention for dysphagia management.
Choice B reason: Elevating the head of the bed to 45 degrees or higher during meals can help prevent aspiration in
clients with dysphagia.
Choice C reason: Telling a client with dysphagia to tilt their head back while swallowing can increase the risk of aspiration.
Choice D reason: Turning on the television is not a recommended practice as it can distract the client from focusing
on safe swallowing techniques.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Choice A reason: Testing the balloon is important, but it is not the action to take immediately before insertion.
Choice B reason: While cleaning the urinary meatus is necessary, using one cotton swab is not sufficient for proper aseptic technique.
Choice C reason: Donning sterile gloves is essential to maintain an aseptic technique during catheter insertion to prevent infection.
Choice D reason: An oil-based lubricant should not be used as it can increase the risk of infection and is not compatible with the catheter material; a water-soluble lubricant is recommended.
Correct Answer is B
Explanation
Choice A reason: Granola may contain ingredients like nuts and dried fruits that are high in potassium, which is not
suitable for a low potassium diet.
Choice B reason: Many salt substitutes contain potassium chloride instead of sodium chloride, and using them can increase potassium intake, which is not recommended for a client on a low potassium diet.
Choice C reason: Molasses is high in potassium, so replacing sugar with molasses when baking would not be
appropriate for someone on a low potassium diet.
Choice D reason: Orange juice is high in potassium compared to apple juice, making it an unsuitable choice for
someone on a low potassium diet.
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