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

Explanation

a. “The client is in the radiology department for a chest x-ray.”

This information is relevant as it informs the oncoming nurse about the client's current location and the reason for the absence from the unit. It helps maintain awareness of the client's whereabouts and the ongoing diagnostic process.

b. “The client’s partner came to visit him 2 hrs. ago.”

While it's important to document visitor interactions in the client's chart, informing about a visit from 2 hours ago during a change-of-shift report may not be as pertinent to immediate patient care as other information. This detail can be communicated through other means, such as the client's chart or communication log.

c. “The client has routine vital signs prescribed.”is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.

d. “The client is the president of a local bank.”

While interesting, this information is not relevant to the client's current medical condition or care plan. It does not contribute to the immediate care needs of the client and can be considered extraneous during a change-of-shift report.

A. Involve the client’s partner to assist with the teaching session B. Incorporate gestures and hand signals when presenting information C. Validate understanding by interpreting the client’s body language D. Provide an interpreter when obtaining consent from the client

Correct Answer is D

Explanation

a. Involve the client’s partner to assist with the teaching session: While involving the client's partner can be helpful, it may not ensure effective communication if the partner also does not speak the same language as the client.

b. Incorporate gestures and hand signals when presenting information: This is an effective strategy to enhance communication with a client who speaks a different language. Non-verbal cues such as gestures and hand signals can help convey meaning and facilitate understanding.

c. Validate understanding by interpreting the client’s body language: Interpreting the client's body language can be helpful in assessing their level of understanding and engagement. However, it may not be sufficient for effective communication, especially if the client has questions or needs clarification.

d. Provide an interpreter when obtaining consent from the client: This is the most appropriate intervention. Using a professional interpreter ensures accurate communication between the nurse and the client, facilitating understanding and ensuring that the client's rights are upheld during the consent process.

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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 A

Explanation

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Correct Answer is D

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