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
Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences .
Choice A is not the answer because providing a physical demonstration may be helpful in teaching a skill, but it does not actively engage the clients in problem-solving .
Choice C is not the answer because incorporating verbal analogies can help clients understand concepts, but it does not actively engage them in problem-solving .
Choice D is not the answer because offering positive reinforcement can encourage and motivate clients, but it does not actively engage them in problem-solving .
Correct Answer is ["16"]
Explanation
The healthcare provider prescribed 800,000 units of penicillin and the vial available is labeled 50,000 units/mL.
To calculate the number of mL to administer, you need to divide the total number of units prescribed (800,000) by the number of units per mL (50,000).
This gives you a result of 16 mL.
Therefore, the nurse should administer 16 mL of penicillin to the patient.
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