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?

Administer liquids to the client using a syringe.

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

Instruct the client to tilt their head back when swallowing.

Request a speech therapist consult from the provider.

Answer and Explanation

The Correct Answer is D

A) Administer liquids to the client using a syringe:

Administering liquids using a syringe may not address the underlying issue of food pocketing in the client's cheeks during meals. While syringe feeding may be necessary for clients with severe dysphagia, it does not address the need for comprehensive evaluation and intervention by a speech therapist.

B) Elevate the head of the client's bed to 45° during meals:

Elevating the head of the bed during meals is a standard intervention to help prevent aspiration in clients with dysphagia. While this intervention may be appropriate, it may not directly address the issue of food pocketing in the client's cheeks. Therefore, it is not the most comprehensive intervention for this specific problem.

C) Instruct the client to tilt their head back when swallowing:

Tilting the head back when swallowing is not a recommended intervention for clients with dysphagia. In fact, this maneuver can increase the risk of aspiration, as it can cause food or liquid to enter the airway. Therefore, this intervention would not be appropriate and could potentially exacerbate the client's swallowing difficulties.

D) Request a speech therapist consult from the provider:

This is the most appropriate intervention for addressing the client's dysphagia and food pocketing. Speech therapists are trained to assess and treat swallowing disorders, including pocketing of food in the cheeks. They can conduct a comprehensive evaluation of the client's swallowing function and develop individualized interventions to address the underlying causes of dysphagia. Therefore, requesting a speech therapist consult is the most effective way to manage this issue and improve the client's swallowing safety and efficiency.

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Correct Answer is A

Explanation

A) Perform CPR on the client:

Performing CPR is a critical intervention during cardiac arrest to maintain circulation and oxygenation. Assistive personnel are trained in basic CPR techniques and can effectively administer chest compressions according to established protocols. Assigning this task to assistive personnel allows the nurse to focus on other aspects of resuscitation and coordination of care.

B) Assist with airway intubation:

Airway intubation requires specialized training and skills, typically performed by licensed healthcare providers such as nurses or physicians. While assistive personnel may assist with preparing equipment or positioning the client, they are not trained to perform airway intubation procedures.

C) Place defibrillator pads on the client:

Placing defibrillator pads requires knowledge of proper positioning and electrode placement to deliver effective defibrillation shocks. This task is typically performed by healthcare providers with training in advanced cardiac life support (ACLS). Assistive personnel may assist with tasks such as preparing the client's chest and clearing the area for defibrillation, but they do not typically apply the pads themselves.

D) Maintain IV access:

Maintaining IV access involves monitoring the IV site, adjusting flow rates, and administering medications or fluids as ordered. While assistive personnel may assist with tasks related to IV access, such as holding the IV bag or adjusting tubing, they are not typically responsible for the overall management and maintenance of IV access during a cardiac arrest situation.

A. Contact the nurse from the previous shift to report the doubled dose. B. Document the doubled dose in the client's medical record. C. Place a copy of the incident report in the client's record. D. Report the incident to the manager of the pharmacy.

Correct Answer is B

Explanation

A) Contact the nurse from the previous shift to report the doubled dose:

While it may be appropriate to communicate with the nurse from the previous shift to gather information about the medication administration, contacting them solely to report the doubled dose may not be the most effective action. The priority is to ensure appropriate documentation of the incident and take necessary steps to address it.

B) Document the doubled dose in the client's medical record:

Documenting the doubled dose in the client's medical record is essential for accurate and transparent documentation of the incident. This documentation should include details such as the medication, dosage, time of administration, and any actions taken in response to the error. It ensures that all members of the healthcare team are aware of what occurred and facilitates appropriate follow-up and monitoring.

C) Place a copy of the incident report in the client's record:

While completing an incident report is necessary to formally document the medication error and initiate an investigation, simply placing a copy of the report in the client's record may not be sufficient. The incident report typically serves as an internal document used for quality improvement purposes and may not be part of the client's official medical record.

D) Report the incident to the manager of the pharmacy:

Reporting the incident to the manager of the pharmacy may be appropriate for addressing potential medication dispensing errors or system issues but may not be the immediate action required when a medication error occurs at the administration stage. The first priority is to ensure accurate documentation of the error in the client's medical record.

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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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Correct Answer is A

Explanation

A nurse is reviewing a client's medical record and discovers that the client received a double dose of a prescribed medication. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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