A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching?
Give the client a straw to use for drinking.
Place oral suction equipment next to the client's bedside.
Provide thin liquids to help the client swallow.
Use a needleless syringe to instill feedings.
The Correct Answer is B
A. "Give the client a straw to use for drinking" is incorrect. Straws are not recommended for clients with dysphagia because they can increase the risk of aspiration. It is better to use a cup to control the amount of liquid ingested and reduce choking risk.
B. "Place oral suction equipment next to the client's bedside" is correct. For clients with dysphagia, having oral suction equipment readily available can help clear the airway quickly in case of aspiration or choking. It is an important safety measure in the management of dysphagia.
C. "Provide thin liquids to help the client swallow" is incorrect. Thin liquids can increase the risk of aspiration for clients with dysphagia. It is often recommended to provide thickened liquids, as they are easier to swallow and less likely to be aspirated.
D. "Use a needleless syringe to instill feedings" is incorrect. The use of a needleless syringe for feeding is generally not appropriate for clients with dysphagia unless specifically recommended for feeding via a tube. Otherwise, feeding should be done carefully with consideration for the type and consistency of the food.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "This must be very frightening for you. Let's talk more about it.": This response demonstrates empathy and validation of the client's feelings, which can help build trust. It acknowledges the client's emotional state while not challenging or confronting their delusion directly. This approach helps maintain rapport while encouraging the client to express themselves.
B. "What makes you think the staff is following you?": This response could be perceived as questioning the validity of the client's experience, which may feel confrontational or invalidating. It is not the best approach for engaging a client with paranoid delusions.
C. “Why do you feel the staff is the FBI?": This question could also challenge the client's delusion and inadvertently reinforce their sense of being persecuted. Asking such a question might escalate anxiety rather than calm the client.
D. "The psychiatric staff is not FBI. They are here to help you.": While this response is factually correct, it may be perceived as dismissive of the client's experience. Confronting the delusion directly is generally not helpful and can increase the client's feelings of mistrust.
Correct Answer is A
Explanation
A. Frequently checking the top of the ears for sores is correct. The nasal cannula tubing can cause pressure injuries behind the ears over time. The family should check for redness or sores and use protective padding or adjust the tubing as needed.
B. Turning the oxygen up to 10 when the client has trouble breathing is incorrect. Oxygen flow rates should be adjusted only as prescribed by the provider. Increasing the flow rate without guidance can lead to complications, such as oxygen toxicity in clients with chronic respiratory conditions.
C. Using petroleum jelly to keep the nares moist is incorrect. Petroleum-based products are flammable and should not be used with oxygen therapy. Instead, a water-based lubricant should be used to prevent nasal dryness.
D. Removing the nasal cannula when eating is incorrect. Clients using a nasal cannula can continue wearing it while eating, as it allows them to receive oxygen continuously. If needed, a healthcare provider can recommend adjustments to oxygen flow during meals.
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