A nurse is supervising 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?
Providing a 10min 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
The Correct Answer is B
a. Providing a rest period prior to meals may be appropriate for some clients, but 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 helps prevent aspiration and facilitates swallowing in clients with dysphagia.
c. Instructing the client to place her chin toward her chest when swallowing is not recommended and may increase the risk of aspiration.
d. Withholding fluids until the end of the meal is not recommended for clients with dysphagia, as they may need fluids to help with swallowing and to prevent dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. “The client is in radiology department for a chest x-ray” Rationale:
a. The client's location in the radiology department is pertinent information for the oncoming nurse as they have to account for the patient’s whereabouts.
b. While family involvement is important, the timing of the partner's visit is not essential information for the oncoming nurse unless there were significant developments during the visit. c. This is expected of nursing practice.
d. The client's occupation or social status is not relevant to the immediate care needs and should not typically be included in a change-of-shift report.
Correct Answer is C
Explanation
a. Measuring oxygen saturation requires nursing judgment and assessment skills, which are beyond the scope of practice for an assistive personnel (AP).
b. Nasal hygiene for a client with an NG tube involves specific skills and requires nursing assessment to ensure proper technique and patient comfort.
c. Pouching a client's ostomy bag involves routine care that can be safely performed by assistive personnel under the direction and supervision of a nurse.
d. Inserting a rectal suppository requires nursing judgment and assessment to determine appropriateness based on the client's condition, which is beyond the scope of practice for an AP.
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