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. Bite block: This is not the correct choice. A bite block is used to prevent a patient from biting down on tubes or other equipment, not typically required for a patient with dysphagia.
- B. Yankauer suction device: This is the correct choice. A Yankauer suction device is used to clear the oral cavity of secretions or food particles, which is essential for a patient with dysphagia to prevent aspiration.
- C. Large-handled utensils: While these may be helpful for a patient with dysphagia to feed themselves more easily, they are not as critical as ensuring the airway is clear of obstructions.
- D. Nasal cannula and oxygen: This equipment would be necessary if the patient had respiratory issues, but it is not specifically related to the management of dysphagia.
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Related Questions
Correct Answer is D
Explanation
A. The facility ethics committee can provide guidance and recommendations, but they do not have the authority to override a competent client's decision regarding their own medical treatment. Their role is advisory rather than decisive.
B. While a client's refusal based on religious beliefs must be respected, it is not the primary deciding factor in this scenario. The key issue is the client's understanding and informed consent, regardless of the reason for refusal.
C. If the partner is the client's durable power of attorney for health care, they can make decisions on behalf of the client only if the client is deemed incompetent. In this case, the client is competent and has made their own decision.
D. The client's understanding of the risks associated with refusing the procedure is crucial. Informed consent requires that the client comprehends the potential consequences of their decision, ensuring that their refusal is based on a clear understanding of the risks involved.
Correct Answer is A
Explanation
A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is the highest priority. An absent pedal pulse indicates potential arterial occlusion, which could lead to tissue ischemia and necrosis if not addressed promptly. This situation is critical and requires immediate intervention to restore circulation and prevent permanent damage.
B. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (101°F) is not the highest priority. A mild fever in a client with MRSA indicates infection, but it is not immediately life-threatening. This client needs monitoring and possible adjustment of antibiotics, but the situation does not require urgent intervention.
C. A client who is postoperative following a laminectomy 12 hr ago and is unable to void is concerning, as it could indicate a complication such as urinary retention or spinal nerve damage. However, it is not immediately life-threatening and can be addressed after the more critical issue of a potential arterial occlusion in the client with peripheral vascular disease
D. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy: While this client's diagnosis and treatment plan are significant, they may not require immediate intervention compared to the potential complications of urinary retention in the postoperative client.
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