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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:
a. Administering an enema for a scheduled endoscopy is within the scope of practice for an LPN. It involves a task that is repetitive, stable, and does not require critical thinking.
b. Developing an initial plan of care for a client with sickle cell anemia involves critical thinking and assessment, which are within the scope of practice for an RN.
c. A client transferring from the CCU after a myocardial infarction requires close monitoring and assessment, which are typically within the scope of practice for an RN.
d. Teaching a newly admitted client about self-administration of insulin involves education, assessment, and critical thinking, which are typically within the scope of practice for an RN.

A. Alert the infection control department B. Discuss the issue with the AP C. Reinforce facility protocols at the next staff meeting D. Notify the unit manager about the incident

Correct Answer is B

Explanation

a. While alerting the infection control department is important, directly addressing the issue with the involved personnel should be the initial action.
b. Discussing the issue with the assistive personnel (AP) allows for immediate clarification of the protocol and provides an opportunity to correct the behavior.
c. Reinforcing facility protocols at a staff meeting may be necessary but should not be the first step when immediate action is required.
d. Notifying the unit manager is important, but addressing the issue with the AP directly is the first step in resolving the situation and preventing future occurrences.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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