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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inadequate food supply is a basic physiological need that directly affects recovery, wound healing, and overall postoperative outcomes after coronary artery bypass grafting. Ensuring access to adequate nutrition is essential for physical recovery and takes priority in discharge planning.
B. Limited social support is important for long-term recovery and adherence to care but does not address an immediate physiological need. It is typically addressed after basic needs are secured.
C. Low pain tolerance affects comfort and recovery experience but is managed through pain control strategies and does not take priority over essential survival needs like nutrition.
D. Decreased self-esteem is a psychosocial concern that, while important for holistic recovery, is addressed after physiological and safety needs have been met.
Correct Answer is C
Explanation
A. Instructing the AP to request assistance when unsure about a task is important for future situations, but it does not immediately address the current incorrect transfer, which could pose a risk to the client.
B. Demonstrating the proper client transfer technique for the AP directly addresses the immediate issue, ensuring the client is safely transferred and the AP learns the correct method through observation and practice.
C. Helping the AP assist the client with the transfer ensures the client's safety in the moment, but it does not provide the AP with the knowledge or skills needed to perform the task correctly in the future.
D. Referring the AP to the facility procedure manual is useful for long-term learning, but it does not provide the immediate guidance needed to correct the current unsafe transfer.
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