A nurse is providing teaching for a group of clients who have dysphagia. Which of the following interventions should the nurse include?

“Use a straw to sip liquids."

“Dry swallow in between bites.”

“Mix foods of different textures into the same bite."

“Assume a chin-up position."

Answer and Explanation

The Correct Answer is B

A. “Use a straw to sip liquids.” Using a straw increases the flow of liquid, making it more difficult to control and increasing the risk of aspiration in clients with dysphagia.

B. “Dry swallow in between bites.” Performing a dry swallow between bites helps clear the throat and esophagus of any remaining food, reducing the risk of aspiration and ensuring that each bite is swallowed completely before taking another.

C. “Mix foods of different textures into the same bite.” Combining textures (e.g., liquid and solid) can confuse swallowing reflexes and increase aspiration risk. Foods should be uniform in consistency.

D. “Assume a chin-up position.” A chin-up position opens the airway and increases aspiration risk. The correct position is a chin-down (chin-tuck) posture, which helps protect the airway during swallowing.

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Free Nursing Study Resources

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

Explanation

Rationale

A. Obtain a 24 hr urine specimen: This is the gold standard for quantifying proteinuria and diagnosing preeclampsia, but a rapid 3+ protein dipstick and severe symptoms/lab findings have already established the diagnosis of severe preeclampsia/HELLP. Treatment (magnesium sulfate, blood pressure control, and preparation for delivery) should not be delayed to wait for a 24-hour collection.

B. Monitor intake and output hourly: Clients with preeclampsia are at risk for renal impairment and fluid overload due to vasospasm and endothelial injury. Hourly monitoring ensures adequate renal perfusion (goal urine output ≥30 mL/hr) and prevents complications like pulmonary edema.

C. Administer betamethasone: At 31 weeks’ gestation, preterm delivery is likely if maternal or fetal status deteriorates. Betamethasone promotes fetal lung maturity, reducing the risk of respiratory distress syndrome in the newborn.

D. Provide a low-stimulation environment: A quiet, dimly lit room minimizes external triggers that can increase CNS irritability and lower the seizure threshold in severe preeclampsia. This is essential for preventing eclampsia.

E. Give antihypertensive medication: Severe BP readings (≥160/110 mm Hg) require prompt pharmacologic intervention (e.g., labetalol, hydralazine) to reduce the risk of stroke or placental abruption while maintaining uteroplacental perfusion.

F. Maintain bedrest: Activity restriction (preferably left lateral position) enhances uteroplacental blood flow and decreases BP. It also helps prevent falls or injury if the client becomes symptomatic or experiences a seizure.

G. Perform a vaginal examination every 12 hr: This is contraindicated in clients with preeclampsia who are not in active labor. Vaginal examinations may induce uterine contractions and increase infection risk without clinical benefit. Cervical assessment should only be done if delivery is imminent or indicated by the provider.

A. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field. B. Place objects 1.27 cm (0.5 in) inside the border of the sterile field. C. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container. D. Hold the sterile package in his dominant hand and open the top flap of the package toward his body.

Correct Answer is A

Explanation

A. Sterile items should be dropped from approximately 15–30 cm (6–12 inches) above the sterile field to prevent contamination from the nurse’s hand or sleeve while maintaining accuracy in placement. This allows the item to land gently without touching the edges.

B. The 2.5 cm (1 inch) border around the sterile field is considered contaminated. Placing items only 0.5 inch from the edge risks touching the contaminated border, so this action is incorrect.

C. When pouring a sterile solution, the nurse should hold the bottle with the label facing the palm and pour the solution without crossing over the sterile field. The lip of the bottle should be above, not outside, the sterile container to prevent contamination from splashing.

D. The first flap of a sterile package should always be opened away from the body to avoid contamination of the sterile field by the nurse’s uniform or hands. Opening it toward oneself is incorrect.

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A nurse is providing teaching for a group of clients who have dysphagia. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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