A nurse is supervising an assistive personnel 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 degrees during mealtime

Instructing the client to place her chin toward her chest when swallowing

Withholding fluids until the end of the meal

Answer and Explanation

The Correct Answer is C

a. Providing a 10-minute rest period prior to meals:

This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.

b. Elevating the head of the client’s bed to 30 degrees during mealtime:

The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.

c. Instructing the client to place her chin toward her chest when swallowing:

This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.

d. Withholding fluids until the end of the meal:

Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.

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Correct Answer is B

Explanation

a. MS 10 mg IV every 4 prn for pain

This choice is incorrect because it lacks clarity and proper formatting. "MS" could be misunderstood as "morphine sulfate," but it's not specified. Additionally, "every 4 prn for pain" is not a standard way to write a prescription. It should indicate the frequency (e.g., every 4 hours) and the indication for administration (e.g., prn for pain).

b. Morphine sulfate 10 mg IV q 4 hr IV prn for pain

This choice is the correct transcription of the prescription. It clearly states the medication (morphine sulfate), the dosage (10 mg), the route (IV), the frequency (every 4 hours), and the indication for administration (prn for pain).

c. MSO4 10 mg IVP q 4 prn for pain

This choice is incorrect due to the use of abbreviations that may not be universally understood. While "MSO4" likely stands for morphine sulfate, it's preferable to write it out completely to avoid confusion. Additionally, "q 4" is not clear and should be written as "every 4 hours."

d. Morphine sulfate 10.0 mg every 4 hours IV prn for pain

This choice is incorrect because it specifies the dosage with unnecessary precision (10.0 mg instead of 10 mg). While this level of precision is not typically required in medication prescriptions, it doesn't make the prescription incorrect per se. However, it's not the most common or standard way to write medication orders.

A. Document in the client’s chart that an incident report has been filed B. Call risk management to interview the client C. Contact the nurse manager D. Reassure the client that the staff is well trained

Correct Answer is C

Explanation

a. Document in the client’s chart that an incident report has been filed:

Documenting that an incident report has been filed is an important step in the process of addressing the client's complaint. It ensures that there is a record of the incident and initiates the appropriate follow-up procedures.

b. Call risk management to interview the client:

In long-term care facilities, risk management departments are responsible for investigating incidents and ensuring that appropriate measures are taken to prevent future occurrences. In this situation, involving risk management may be necessary to conduct a thorough investigation.

c. Contact the nurse manager:

The nurse manager is responsible for overseeing the nursing staff and ensuring that quality care is provided to clients. Contacting the nurse manager allows for immediate notification of the incident and enables them to initiate the appropriate steps to address the situation.

d. Reassure the client that the staff is well trained:

While it's important to provide reassurance to the client, simply reassuring them without taking any further action may not adequately address their concerns or prevent similar incidents from occurring in the future.

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A nurse is supervising an assistive personnel who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

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Explanation

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Explanation

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