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
When feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration, the head of the bed should be elevated 45 to 90 degrees to prevent aspiration1.
Therefore, if the UAP raises the head of the bed to only 80 degrees, it indicates the need for additional teaching.
Choice A is not correct because placing food on the unaffected side of the mouth is an appropriate action when feeding a client with a CVA.
Choice C is not correct because positioning the head with the chin tilted slightly downward can help prevent aspiration.
Choice D is not correct because allowing 30 minutes of rest before feeding can help improve digestion and reduce the risk of aspiration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
When administering ear drops to an adult client with an ear infection, the nurse should keep the patient in a supine position to administer the drops.
This position allows the medication to flow into the ear canal and reach the site of infection.
Choice A is not correct because it is not necessary to swab and shake the bottle before administering the drops.
Choice B is not correct because tilting the head upright would cause the medication to flow out of the ear canal instead of reaching the site of infection.
Choice C is not correct because lowering the edge of the dropper into the canal of the ear could cause injury or discomfort to the patient.
Correct Answer is C
Explanation
Sensory overload happens when an individual is getting more input from their senses than their brain can sort through and process 1.
Therefore, reducing the stimuli in the area can help the client’s brain to better process the information being taught.
Choice A is not the answer because demonstrating the skill speaking slowly and using simple terms does not address the issue of sensory overload 1.
Choice B is not the answer because reassuring the client that the skill is not difficult to learn does not address the issue of sensory overload 1.
Choice D is not the answer because providing step-by-step written instruction does not address the issue of sensory overload 1.
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