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 A

No explanation

A. A client who is scheduled for an endoscopy later today and requires an enema B. A newly admitted client who has sickle cell anemia and requires the development of an initial plan of care C. A client who had a myocardial infraction and will be transferring to the unit from the CCU D. A newly admitted client who has diabetes mellitus and requires initial teaching on self- administration of insulin

Correct Answer is A

Explanation

a. A client who is scheduled for an endoscopy later today and requires an enema:

Administering an enema involves basic nursing care, which falls within the scope of practice of an LPN. LPNs are trained to perform such tasks under the supervision of a registered nurse (RN).

b. A newly admitted client who has sickle cell anemia and requires the development of an initial plan of care:

Developing an initial plan of care involves comprehensive assessment, critical thinking, and the ability to formulate nursing diagnoses and interventions. This task typically falls within the scope of practice of the RN, who has advanced education and training in care planning and coordination.

c. A client who had a myocardial infarction and will be transferring to the unit from the CCU:

Transferring a client from one unit to another may involve coordinating care, ensuring continuity of care, and communicating with other members of the healthcare team. This task may be more appropriate for an RN, who has the knowledge and skills to manage such transitions safely and effectively.

d. A newly admitted client who has diabetes mellitus and requires initial teaching on self-administration of insulin:

Providing client education, especially on self-care management such as insulin administration, requires knowledge of disease processes, medication administration, and patient teaching techniques. This task is typically within the scope of practice of the RN, who can assess the client's learning needs, provide tailored education, and evaluate the client's understanding and competency.

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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

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Explanation

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