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?
Withholding fluids until the end of the meal
Elevating the head of the client's bed to 30 degrees during mealtime
Providing a 10-minute rest period prior to meals
Instructing the client to place her chin toward her chest when swallowing
The Correct Answer is D
Choice A reason: This is not a correct technique for feeding a client who has dysphagia. Withholding fluids until the end of the meal can increase the risk of dehydration and aspiration. Fluids should be offered throughout the meal to help moisten and thin the food.
Choice B reason: This is not a correct technique for feeding a client who has dysphagia. Elevating the head of the client's bed to 30 degrees during mealtime is not enough to prevent aspiration. The client should be in an upright position, preferably at 90 degrees, to facilitate swallowing and gravity.
Choice C reason: This is not a correct technique for feeding a client who has dysphagia. Providing a 10-minute rest period prior to meals is not necessary and may delay the feeding. The client should be fed when they are alert and hungry, and not too tired or sleepy.
Choice D reason: This is a correct technique for feeding a client who has dysphagia. Instructing the client to place her chin toward her chest when swallowing can help close the airway and prevent food from entering the lungs. This can reduce the risk of aspiration and choking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Taking pictures of the child's injuries once the parent leaves the room is not a correct action, as it violates the child's privacy and dignity. The nurse should not take pictures of the child without the parent's consent and only if it is required by the facility's policy or the law.
Choice B reason: Having a facility security officer interview the parent is not a correct action, as it is not within the scope of the security officer's role and may escalate the situation. The nurse should not involve the security officer unless there is a threat of violence or harm to the child, the parent, or the staff.
Choice C reason: Completing an incident report concerning the child's injuries is not a correct action, as it is not relevant to the child's situation. The nurse should complete an incident report only if there is an adverse event or error that occurred within the facility that affected the child's care or safety.
Choice D reason: Reporting the child's injuries to Child Protective Services is the correct action, as it is the nurse's legal and ethical duty to protect the child from potential abuse or neglect. The nurse should suspect child abuse based on the child's injuries, which are inconsistent with the parent's explanation and indicative of non-accidental trauma. The nurse should follow the facility's protocol and the state's law for reporting suspected child abuse.
Correct Answer is D
Explanation
Choice A reason: This is not the correct choice because this action is not the nurse's responsibility. Coordinating the team and the plan of care is the role of the case manager or the social worker, who can facilitate communication and collaboration among the different disciplines involved in the client's care.
Choice B reason: This is not the correct choice because this action is not the nurse's responsibility. Ordering durable medical equipment for the client's home is the role of the occupational therapist or the physical therapist, who can assess the client's functional needs and abilities and recommend the appropriate devices.
Choice C reason: This is not the correct choice because this action is not the nurse's responsibility. Helping the client obtain financial assistance is the role of the social worker or the financial counselor, who can identify the client's eligibility and options for funding and insurance coverage.
Choice D reason: This is the correct choice because this action is the nurse's responsibility. Performing a dietary assessment is part of the nursing process and the scope of practice of the nurse, who can evaluate the client's nutritional status and needs and provide education and counseling on diet modifications and interventions.
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