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 C

Explanation

a. Review current literature regarding client falls:

This option involves conducting a review of existing research and literature on client falls. Reviewing current literature can provide valuable insights into evidence-based practices and interventions for fall prevention. However, conducting a literature review typically follows problem identification and is part of the process of developing an evidence-based approach to addressing the issue.

b. Implement a fall prevention plan:

Implementing a fall prevention plan involves putting in place strategies and interventions aimed at reducing the risk of falls among clients. While implementing a fall prevention plan is an essential step in addressing the issue, it should be based on a thorough assessment of clients at risk for falls (which comes before planning interventions) to ensure that interventions are targeted and effective.

c. Identify clients who are at risk for falls:

This is the most appropriate first step in the quality improvement process. Identifying clients who are at risk for falls allows healthcare providers to focus interventions on those who are most vulnerable. It involves conducting comprehensive assessments, considering factors such as age, mobility, cognitive status, medications, and history of falls, to determine individual risk levels.

d. Notify staff of the increased fall rate:

While communication with staff about the increased fall rate is important for raising awareness and promoting a culture of safety, it should not be the first action taken in the quality improvement process. Before notifying staff, it's essential to identify clients at risk for falls and develop targeted interventions to address the issue effectively.

A. A client who is 37 weeks of gestation and has an L/S ratio of 2:1 B. A client who is at 28 weeks of gestation and has a negative Coombs’ titer C. A client who is at 39 weeks of gestation and has a negative contraction stress test D. A client who is at 35 weeks of gestation and has a biophysical profile of 6

Correct Answer is D

Explanation

a. A client who is 37 weeks gestation and has an L/S ratio of 2:1:

An L/S (Lecithin/Sphingomyelin) ratio of 2:1 indicates mature fetal lungs, which is a positive indicator. While this client may be nearing term, the presence of mature fetal lungs does not necessarily warrant an interdisciplinary care conference unless there are other complications or high-risk factors present.

b. A client who is 28 weeks gestation and has a negative Coombs's titer:

A negative Coombs's titer suggests that the client does not have antibodies against Rh-positive blood cells, which is a normal finding. At 28 weeks gestation, this client may not require an interdisciplinary care conference unless there are other significant complications or risk factors present.

c. A client who is at 39 weeks gestation and has a negative contraction stress test:

A negative contraction stress test indicates that the fetus is not experiencing distress during uterine contractions, which is a reassuring finding. At 39 weeks gestation, while this client may be nearing term, a negative contraction stress test alone may not warrant an interdisciplinary care conference unless there are other concerning factors present.

d. A client who is at 35 weeks gestation and has a biophysical profile of 6:

A biophysical profile (BPP) of 6 is on the lower end of the scale and may indicate potential fetal compromise or risk. This client may benefit from further evaluation and possibly closer monitoring, which could warrant an interdisciplinary care conference to discuss management and potential interventions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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