A charge nurse is assessing the room of a newly admitted client who has dysphagia. Which of the following pieces of equipment should the nurse ensure is available in the client's room?
Bite block
Yankauer suction device
Large-handled utensils
Nasal cannula and oxygen
The Correct Answer is B
A. A bite block is not typically needed for a client with dysphagia, as it is more commonly used in situations where the airway needs to be protected, such as during seizures or certain dental procedures.
B. A Yankauer suction device should be readily available for a client with dysphagia. Dysphagia increases the risk of aspiration, which can lead to choking or pneumonia. A Yankauer suction device allows for oral suctioning to clear secretions or food particles from the mouth and airway to help prevent aspiration and maintain a patent airway.
C. While large-handled utensils may be helpful for clients with limited dexterity or mobility (such as those with arthritis), they are not essential equipment for managing dysphagia.
D. Nasal cannula and oxygen: Oxygen therapy is not a routine intervention for dysphagia unless the client has respiratory complications that require supplemental oxygen. While aspiration can lead to respiratory issues like aspiration pneumonia, a nasal cannula and oxygen are not immediate necessities in the room for a client with dysphagia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"The nurse verbalizes their understanding of the plan," is important, verbalizing understanding does not necessarily guarantee successful implementation of the plan. Action is required to demonstrate competence and improvement.
Choice B Reason:
The nurse performs all tasks as specified is correct. The effectiveness of a performance improvement plan is best determined by observing whether the nurse successfully implements the specified tasks and achieves the desired improvements in their performance. Therefore, option B, "The nurse performs all tasks as specified," is the most appropriate outcome to indicate the effectiveness of the plan.
Choice C Reason:
"The nurse attends a critical thinking class," may be a component of the performance improvement plan, but attending a class alone does not necessarily indicate whether the nurse's performance has improved.
Choice D Reason:
"The nurse shares their performance plan with another nurse," is not a direct measure of the effectiveness of the plan. Sharing the plan with another nurse may demonstrate openness and willingness to seek support, but it does not necessarily indicate whether the nurse has successfully improved their performance as a result of the plan.
Correct Answer is B
Explanation
Choice A Reason:
Reinforcing facility protocols at the next staff meeting, is important for reminding all staff members of the importance of following protocols, but it may not address the immediate issue at hand.
Choice B Reason:
Discussing the issue with the AP is correct. When a charge nurse witnesses an assistive personnel (AP) failing to follow facility protocol, the first action should be to directly address the issue with the AP. This allows for immediate feedback and correction of behavior, helping to ensure that proper procedures are followed in the future.
Choice C Reason:
Alerting the infection control department, may be necessary if the violation poses a risk of infection transmission, but it may not be the first step. Directly addressing the issue with the AP allows for immediate correction and prevents potential harm.
Choice D Reason:
Notifying the unit manager about the incident, is also important, but addressing the issue with the AP directly is the immediate action needed to correct the behavior.
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