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 B
Explanation
Choice A reason: This is not the information that the nurse should include in the change-of-shift report. The time the client received his last dose of pain medication is not relevant to the transfer to the rehabilitation facility. The nurse should document the pain medication administration in the medication record and communicate it to the receiving nurse.
Choice B reason: This is the information that the nurse should include in the change-of-shift report. The steps to follow when providing wound care are important to ensure the continuity and quality of care for the client. The nurse should explain the type, location, and condition of the wound, the dressing materials and frequency, and any signs of infection or complications.
Choice C reason: This is not the information that the nurse should include in the change-of-shift report. The client's preferred time for bathing is not essential to the transfer to the rehabilitation facility. The nurse should respect the client's preferences and routines, but they are not a priority for the report.
Choice D reason: This is not the information that the nurse should include in the change-of-shift report. The belief that the client has a difficult relationship with his son is not based on facts and may be biased or inaccurate. The nurse should avoid making assumptions or judgments about the client's family dynamics and focus on the objective data and the client's needs.
Correct Answer is D
Explanation
Choice A reason: I should discard personal health information documents in the trash before leaving the unit is not a correct statement, as it violates the client's privacy and the Health Insurance Portability and Accountability Act (HIPAA). I should shred or dispose of personal health information documents in a secure container or according to the facility's policy.
Choice B reason: I can post the client's vital signs in the client's room is not a correct statement, as it exposes the client's health information to unauthorized persons. I should keep the client's vital signs confidential and only share them with the client and the health care team.
Choice C reason: I can use another nurse's password as long as I log off after using the computer is not a correct statement, as it compromises the security and integrity of the electronic health record. I should use my own password and never share it with anyone else.
Choice D reason: I should encrypt personal health information when sending emails is a correct statement, as it protects the client's privacy and the HIPAA. I should use encryption or other secure methods when transmitting personal health information electronically.
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