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 C
Explanation
Choice A reason: Obtaining a prescription for a sedative for the client is not a correct action, as it may cause adverse effects such as confusion, falls, or respiratory depression. The nurse should avoid using sedatives unless absolutely necessary and use non-pharmacological interventions to calm the client.
Choice B reason: Removing the clock and calendar from the client's room is not a correct action, as it may worsen the client's disorientation and anxiety. The nurse should provide orientation cues such as a clock, a calendar, a radio, or a newspaper to help the client maintain a sense of time and reality.
Choice C reason: Providing distractions for the client during the day is a correct action, as it may reduce the client's boredom, agitation, and wandering behavior. The nurse should engage the client in meaningful activities such as music, games, crafts, or exercise that suit the client's interests and abilities.
Choice D reason: Raising all four side rails on the client's bed is not a correct action, as it may increase the risk of injury or entrapment if the client tries to climb over them. The nurse should use the least restrictive measures to prevent wandering, such as alarms, locks, or supervision.
Correct Answer is A
Explanation
Choice A reason: A nurse places a mask on a client with tuberculosis before transport to the radiology department is a safe handling technique, as it prevents the transmission of airborne pathogens to other clients and staff. The nurse should also wear a respirator and follow the standard and airborne precautions.
Choice B reason: A nurse cleans up a blood spill with hydrogen peroxide is not a safe handling technique, as it can damage the skin and mucous membranes and cause irritation and infection. The nurse should use a bleach solution or an approved disinfectant to clean up blood spills and follow the standard and contact precautions.
Choice C reason: A nurse removes her gown after leaving the client's room is not a safe handling technique, as it can contaminate the environment and expose the nurse to infectious agents. The nurse should remove the gown before leaving the client's room and dispose of it in a designated receptacle.
Choice D reason: A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen is not a safe handling technique, as it can introduce bacteria into the urinary tract and cause infection. The nurse should use a sterile syringe and needle to aspirate the specimen from the sampling port and follow the standard and contact precautions.
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