The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.
Which action by the UAP should the nurse recognize indicates the need for additional teaching?
Places food on the unaffected side of the mouth.
Raises the head of the bed to 80 degrees.
Positions the head with the chin tilted slightly downward.
Allows 30 minutes of rest before feeding.
The Correct Answer is B
A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.
B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.
C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.
D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Pressure redistribution is an important part of preventing and treating pressure sores1.
Choice A is not the answer because offering oral fluids does not directly address the issue of pressure sores.
Choice C is not the answer because debridement is a surgical procedure that removes dead tissue from a wound and may not be necessary in this case.
Choice D is not the answer because checking for anemia and sensitivity does not directly address the issue of pressure
Correct Answer is C
Explanation
Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive.
A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed 1.
Choice A is not the answer because asking questions in a vague, nonspecific format can lead to confusion and misunderstanding.
Choice B is not the answer because getting the most difficult questions over with first can be overwhelming for the client.
Choice D is not the answer because sharing personal values may not put the client at ease and may even make them feel uncomfortable.
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