A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?

Elevate the head of the client's bed to 45" during meals.

Request a speech therapist consult from the provider.

Instruct the client to tilt their head back when swallowing.

Administer liquids to the client using a syringe.

Answer and Explanation

The Correct Answer is B

A.   Elevate the head of the client's bed to 45° during meals: The head should be elevated to 90° to reduce the risk of aspiration during meals.
B.   Request a speech therapist consult from the provider: Speech therapists can assess swallowing difficulties and recommend appropriate strategies.
C.   Instruct the client to tilt their head back when swallowing: This position increases the risk of aspiration by opening the airway during swallowing.
D.   Administer liquids to the client using a syringe: Syringe administration can lead to choking or aspiration and is not a standard feeding practice for dysphagia clients.

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Correct Answer is D

Explanation

A. Disinfect hands using an alcohol-based waterless antiseptic. Alcohol-based hand sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required.
B. Wear an N95 respirator when caring for the client. C. difficile requires contact precautions, not airborne precautions.
C. Provide a room with negative-pressure airflow. Negative-pressure rooms are used for airborne pathogens, not C. difficile.
D. Use diluted bleach to clean soiled equipment. Bleach is effective in killing C. difficile spores and should be used to disinfect contaminated surfaces.

A. Decline documenting the first counseling session. B. Communicate expected behavior to the AP. C. Explain to the AP the consequences of the behavior. D. Allow the AP time to respond to the counseling information. E. Conduct the counseling session with another AP present.

Correct Answer is ["B","C","D"]

Explanation

A. Decline documenting the first counseling session: Documentation is necessary to maintain accurate records of counseling sessions.
B. Communicate expected behavior to the AP: Reinforcing the expectations helps clarify appropriate behavior.
C. Explain to the AP the consequences of the behavior: Understanding potential consequences encourages adherence to confidentiality standards.
D. Allow the AP time to respond to the counseling information: Allowing the AP to respond fosters a two-way communication approach and encourages accountability.
E. Conduct the counseling session with another AP present: Counseling sessions should remain private to maintain confidentiality.

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A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?

Nursing Test Bank

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