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

Rationale for A: An open fracture of the femur is serious and requires prompt treatment, but it does not typically indicate an immediate life threat compared to other conditions.

Rationale for B: Periorbital ecchymosis can indicate facial trauma, but it is not necessarily life-threatening and would not be prioritized as emergent.

Rationale for C: A deep partial thickness burn on the lower extremities is significant and requires treatment, but unless the burn covers a large area or is complicated by other factors, it is not the most critical issue compared to respiratory or cardiovascular threats.

Rationale for D: An asymmetrical thorax may suggest a possible pneumothorax or other significant respiratory issue, which could lead to respiratory distress or failure. This client should be tagged as emergent due to the potential for rapid deterioration.

A. A client who has Type 1 diabetes and uses an insulin pump B. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dl C. A client who is receiving heparin and has an aPTT of 34 seconds D. A client who has orthostatic hypotension and is receiving IV fluids

Correct Answer is B

Explanation

A. Management of Type 1 diabetes with an insulin pump usually involves ongoing monitoring and adjustments but may not necessarily warrant an immediate interdisciplinary conference.
B. This client has a notable risk for pressure ulcers due to the albumin level, necessitating an interdisciplinary approach to prevent or manage these ulcers.
C. While monitoring heparin therapy is crucial, an aPTT of 34 seconds is within the therapeutic range and may not require an urgent interdisciplinary conference.
D. Orthostatic hypotension being managed with IV fluids may need ongoing assessment, but it may not warrant an immediate interdisciplinary conference.

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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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