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.

Answer and Explanation

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.

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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.

A. Elevate the head of the bed to a 45-degree angle B. Apply the client's positive airway pressure device C. Lift and lock the side rails in place D. Remove dentures or other oral appliances

Correct Answer is B

Explanation

The client has difficulty sleeping due to obstructive sleep apnea (OSA), and using a positive airway pressure device can help keep their airway open and prevent dangerous pauses in breathing while they sleep 1.

Choice A is not the answer because elevating the head of the bed to a 45-degree angle may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.

Choice C is not the answer because lifting and locking the side rails in place is a safety measure but does not directly address the client’s OSA 1.

Choice D is not the answer because removing dentures or other oral appliances may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["16"]

Explanation

The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

Correct Answer is B

Explanation

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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?