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
Related Questions
Correct Answer is D
Explanation
Choice A reason: Memory loss is not typically associated with a lack of dietary fiber. Memory loss can be related to various neurological or psychological conditions.
Choice B reason: Bleeding gums are commonly associated with vitamin C deficiency, not a lack of dietary fiber.
Choice C reason: Brittle hair can be associated with poor nutrition in general, but it is not a specific indicator of inadequate fiber intake.
Choice D reason: Constipation is a well-known symptom of inadequate fiber intake. Fiber helps to bulk up the stool
and promotes regular bowel movements.
Correct Answer is C
Explanation
Choice A reason: Wearing sterile gloves is not necessary when draining an ileostomy bag as this is not a sterile procedure. Clean gloves are typically used.
Choice B reason: Washing the skin surrounding the ileostomy with hot water is not recommended as it can cause
irritation. Lukewarm water should be used, and the area should be patted dry.
Choice C reason: Cleaning the end of the ileostomy pouch before clamping is important to maintain hygiene and
prevent contamination when draining the bag.
Choice D reason: The ileostomy bag should be emptied when it is one-third to one-half full to prevent leakage and ensure comfort for the client.
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