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

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is: B.

Choice A reason:

Suctioning a client's long-term tracheostomy is a complex procedure that involves sterile technique and assessment skills that are beyond the scope of assistive personnel's practice. It requires clinical judgment and the ability to respond to complications, which are responsibilities typically reserved for licensed nursing staff.

Choice B reason:

Using a pain rating scale to monitor a client's pain level is a task that can be delegated to assistive personnel. It involves asking the client to rate their pain on a scale, which does not require clinical judgment or advanced skills. The assistive personnel can then report the pain level to the nurse, who will make decisions regarding pain management.

Choice C reason:

Performing a dressing change on a client's peripherally inserted central catheter (PICC) is not within the scope of assistive personnel. This task requires aseptic technique and knowledge of PICC line management to prevent infection and other complications, which are typically the responsibility of the registered nurse or licensed practical nurse.

Choice D reason:

Instructing a client on self-administration of a tap water enema involves teaching and assessment to ensure the client understands and can perform the procedure safely. This is a task that requires licensed nursing knowledge and skills to educate the client and evaluate their competency.

A. The client's code status B. The client's vital signs C. The client's name D. A prescribed consultation

Correct Answer is C

Explanation

Choice A reason: The client's code status is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. The code status indicates the level of resuscitation the client wishes to receive in case of a cardiac or respiratory arrest.

Choice B reason: The client's vital signs are not part of the background information, but rather the assessment section of the SBAR Communication tool. The vital signs reflect the client's current condition and response to treatment.

Choice C reason: The client's name is part of the background information, along with the client's age, diagnosis, reason for admission, and relevant medical history. The background information provides a brief overview of the client's situation and helps to identify the client.

Choice D reason: A prescribed consultation is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. A consultation is a referral to another health care professional for further evaluation or management of the client's condition.

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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

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Correct Answer is C

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