A nurse is caring for a client who is at risk for aspiration pneumonia due to dysphagia. Which of the following actions should the nurse take to prevent this complication?
Tell the client to lie down after eating.
Instruct the client to tuck her chin when swallowing.
Place the client in a Fowler's position to eat.
Encourage the client to drink water before each meal.
The Correct Answer is B
Choice A reason: Telling the client to lie down after eating can increase the risk of aspiration pneumonia, as food or liquids can enter the lungs more easily when lying down.
Choice B reason: Instructing the client to tuck her chin when swallowing can help prevent aspiration pneumonia, as it closes off the airway and directs food or liquids into the esophagus.
Choice C reason: Placing the client in a Fowler's position to eat can help prevent aspiration pneumonia, as it elevates the head and chest and allows gravity to assist with swallowing.
Choice D reason: Encouraging the client to drink water before each meal can increase the risk of aspiration pneumonia, as it can thin out saliva and make it harder to control swallowing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Potassium 3.5 mEq/L is not a finding that indicates fluid volume deficit because it is within the normal range, which is 3.5 to 5.0 mEq/L. Potassium is an electrolyte that regulates nerve and muscle function, acid-base balance, and fluid balance. Potassium level can be affected by various factors, such as diet, medication, kidney function, and dehydration.
Choice B reason: Sodium 145 mEq/L is not a finding that indicates fluid volume deficit because it is within the normal range, which is 136 to 145 mEq/L. Sodium is an electrolyte that regulates blood pressure, blood volume, and fluid balance. Sodium level can be affected by various factors, such as diet, medication, kidney function, and fluid loss.
Choice C reason: Hematocrit 53% is a finding that indicates fluid volume deficit because it is above the normal range, which is 38 to 50% for men and 34 to 46% for women. Hematocrit is the percentage of red blood cells in the total blood volume. Hematocrit level can increase due to dehydration, which causes hemoconcentration or increased blood viscosity.
Choice D reason: HbA1c 5% is not a finding that indicates fluid volume deficit because it is within the normal range, which is less than 5.7%. HbA1c is the percentage of hemoglobin that is attached to glucose. HbA1c level reflects the average blood glucose level over the past two to three months. HbA1c level can be affected by various factors, such as diabetes, anemia, and medication.
Correct Answer is D
Explanation
Choice A reason: Hemoglobin 16 g/dL is within the normal range for adults and does not indicate an adverse effect of TPN.
Choice B reason: Temperature 36.1°C (97°F) is normal and does not indicate an infection or inflammation, which are possible complications of TPN.
Choice C reason: Blood glucose 98 mg/dL is normal and does not indicate hyperglycemia or hypoglycemia, which are common problems associated with TPN.
Choice D reason: Weight gain of 1.5 kg (3 lB. per day is excessive and indicates fluid overload, which can result from too rapid or too high infusion of TPN. Fluid overload can cause edema, hypertension, heart failure, and pulmonary congestion.
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