A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke.

Which of the following instructions should the nurse include?

Encourage brief exercise before meals to promote appetite.

Place the client with the head reclined back to facilitate swallowing.

Encourage the client to take small bites.

Place food in the affected side of the mouth.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Encouraging brief exercise before meals to promote appetite is not directly related to feeding safety for a client who has dysphagia following a stroke.
Choice B rationale:
Placing the client with the head reclined back to facilitate swallowing is incorrect. It’s safer for the client to sit upright during feeding to prevent aspiration.
Choice C rationale:
Encouraging the client to take small bites can help prevent choking and aspiration, making it a safe feeding practice for clients with dysphagia.
Choice D rationale:
Placing food in the affected side of the mouth is not a safe practice. It’s recommended to place food on the unaffected side of the mouth.

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Correct Answer is D

Explanation

Choice A rationale:
The IV site dressing should be changed every 7 days, not every 4 days.
Choice B rationale:
The client’s blood glucose should be monitored every 4-6 hours, not every 12 hours.
Choice C rationale:
The client should be weighed daily, not every other day.
Choice D rationale:
The IV tubing for TPN should be changed every 24 hours to prevent infection.

A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg. B. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg. C. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg. D. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg.

Correct Answer is A

Explanation

Choice A rationale:
These values indicate metabolic acidosis, which is common in clients with chronic kidney disease. The kidneys are unable to excrete hydrogen ions and reabsorb bicarbonate, leading to a low pH and low bicarbonate levels.
Choice B rationale:
These values indicate alkalosis, not typically associated with chronic kidney disease. The pH is high, indicating a basic or alkaline state, and the bicarbonate level is normal.
Choice C rationale:
These values indicate metabolic alkalosis, which is not typically seen in clients with chronic kidney disease. The pH and bicarbonate levels are both high.
Choice D rationale:
These values indicate respiratory acidosis, not typically associated with chronic kidney disease. The high PaCO2 level indicates that the lungs are not effectively eliminating CO2, leading to acidosis.

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A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke.

Which of the following instructions should the nurse include?