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.
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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Related Questions
Correct Answer is D
Explanation
A. "Have you tried holding your infant skin-to-skin?": Important for bonding and soothing but not the priority for postoperative care.
B. "Have you considered joining a parents' support group?": Beneficial for emotional support but not immediately essential for the infant's recovery.
C. "What is your infant's level of activity?": Relevant for assessing overall recovery but not the most critical issue.
D. "Is your infant able to latch on during breastfeeding?" Feeding is the priority concern after cleft palate repair to ensure adequate nutrition and assess for complications.
Correct Answer is B
Explanation
A. A client who has pneumonia and is receiving 100% oxygen via a non-rebreather mask: This client requires intensive respiratory care and cannot be safely discharged.
B. A client who has ascites and had a paracentesis 4 hr ago: This client is stable following a low-risk outpatient procedure and can be safely managed at home.
C. A client who has a blood glucose level of 380 mg/dL and is receiving insulin via IV infusion: This client has poorly controlled hyperglycemia requiring close monitoring and treatment.
D. A client who is 6 hr postoperative following a hip arthroplasty: This client requires postoperative monitoring and pain management and is at risk for complications.
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