A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia.Which of the following actions by the AP should the nurse identify as correct technique?

Providing a 10 min rest period prior to meals

Elevating the head of the client's bed to 30° during mealtime

Withholding fluids until the end of the meal

Instructing the client to place her chin toward her chest when swallowing

Answer and Explanation

The Correct Answer is B

A: Providing a 10-minute rest period prior to meals can be beneficial for some clients, but it is not specifically related to the prevention of aspiration in clients with dysphagia. Rest periods do not directly facilitate safer swallowing processes.

B: Elevating the head of the client's bed to 30° during mealtime is the correct technique for a client with dysphagia. This position helps prevent aspiration, which can occur if food or liquids enter the lungs instead of going down the esophagus. The semi-upright position aids in the proper alignment of the esophagus and reduces the risk of choking.

C: Withholding fluids until the end of the meal is not an appropriate technique for a client with dysphagia. Fluids are often needed to help swallow and clear the mouth of food particles. Additionally, providing fluids throughout the meal can help prevent dehydration.

D: Instructing the client to place her chin toward her chest when swallowing can help prevent aspiration in clients with dysphagia. However, this technique should be used in conjunction with other methods, such as the correct positioning of the bed, to ensure safety and effectiveness.

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Correct Answer is D

Explanation

A. While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B. Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C. Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D. Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.

A. Place the client's ring in the facility safe. B. Place the ring in the bag with the client's clothing C. Tape the ring securely to the client's finger D. Agree to keep the ring for the client until after surgery.

Correct Answer is A

Explanation

A. Placing the client's ring in the facility safe ensures that it is securely stored and prevents loss or misplacement, which is standard procedure for valuable personal items before surgery.
B. Placing the ring in the bag with the client’s clothing is not secure, as it increases the risk of loss or theft.
C. Taping the ring to the client’s finger is not ideal because jewelry should generally be removed before surgery to prevent complications such as swelling, circulation issues, or electrical burns from cautery equipment.
D. Keeping the ring for the client is inappropriate because staff should not personally hold onto a client’s valuables. Instead, valuables should be properly documented and stored per facility policy.

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A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia.Which of the following actions by the AP should the nurse identify as correct technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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