A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?
Initiate a calorie count of daily food intake.
Provide food in a thin liquid consistency.
Instruct the client to keep their chin up when swallowing.
Place the client in a semi-Fowler's position when eating.
The Correct Answer is D
Choice A rationale:
Initiating a calorie count of daily food intake is not directly related to addressing dysphagia. Calorie counts might be important in certain situations, such as managing weight, but it does not directly address the client's swallowing difficulties.
Choice B rationale:
Providing food in a thin liquid consistency is contraindicated for a client with dysphagia. Thin liquids can increase the risk of aspiration in individuals with swallowing difficulties. The nurse should choose thicker liquids and modify the diet as recommended by a speech-language pathologist or healthcare provider.
Choice C rationale:
Instructing the client to keep their chin up when swallowing is not an appropriate action for addressing dysphagia. Instead, clients with dysphagia are often instructed to tuck their chin down to their chest when swallowing. This helps to close off the airway and prevents food or liquids from entering the airway.
Choice D rationale:
Placing the client in a semi-Fowler's position when eating is the correct action. This position helps prevent aspiration by promoting proper alignment of the airway and esophagus. The semi-Fowler's position involves elevating the head of the bed to an angle of 30-45 degrees. This position facilitates swallowing and reduces the risk of choking or aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Almonds do not contain a high percentage of water. They are a dry and crunchy snack with minimal water content, making them an inappropriate choice for maintaining hydration.
Choice B rationale:
Cheddar cheese is not a food with a high water content. It is a dairy product that has been processed and does not provide a significant source of water to help prevent dehydration.
Choice C rationale:
While whole-wheat bread may have some water content, it is not among the options with the greatest percentage of water. The moisture in bread is not as significant as in other options.
Choice D rationale:
Broccoli contains a substantial amount of water and is an excellent choice for maintaining hydration. It is a water-rich vegetable that can contribute to the body's water needs, making it a suitable recommendation for preventing dehydration.
Correct Answer is B
Explanation
Choice A rationale:
Serum potassium at 4.8 mEq/L is within the normal range (typically around 3.5-5.0 mEq/L), but potassium levels are not the primary concern when assessing the effectiveness of a phosphate binder for end-stage renal disease.
Choice B rationale:
This choice is the correct answer. Total calcium levels around 9.7 mg/dL (normal range approximately 8.5-10.2 mg/dL) are important indicators of the effectiveness of a phosphate binder. These levels reflect the balance between calcium and phosphate in the body, which is crucial for bone health and various physiological functions.
Choice C rationale:
Sodium at 136 mEq/L (normal range approximately 135-145 mEq/L) is within the normal range but is not a direct indicator of the effectiveness of a phosphate binder for end-stage renal disease.
Choice D rationale:
Hemoglobin at 15 g/dL (normal range varies by gender and age but is roughly 12-16 g/dL for adult females and 14-18 g/dL for adult males) is not related to the effectiveness of a phosphate binder. Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are more relevant in assessing anemia or other blood-related conditions.
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