A charge nurse is observing a licensed practical nurse assist a client who has dysphagia while eating. Which of the following actions by the LPN should the charge nurse identify as providing safe care?

Places food on the stronger side of the client’s mouth

Positions the client at a 30 degree angle prior to eating

Instructs the client to hyperextend their neck when swallowing

Has the client sit upright for 20 min following meals

Answer and Explanation

The Correct Answer is A

A. Places food on the stronger side of the client’s mouth: Placing food on the stronger side of the mouth helps the client chew and swallow more effectively and safely. This compensates for weakness on one side, reducing the risk of choking and aspiration.

B. Positions the client at a 30-degree angle prior to eating: A 30-degree angle is insufficient to reduce the risk of aspiration in clients with dysphagia. The client should be positioned in an upright sitting position (90 degrees) to facilitate safer swallowing and reduce the risk of choking or aspirating food.

C. Instructs the client to hyperextend their neck when swallowing: Hyperextending the neck (tilting the head back) can actually increase the risk of aspiration by opening the airway, making it easier for food or liquids to enter the lungs. The client should be encouraged to tuck the chin slightly when swallowing to protect the airway.

D. Has the client sit upright for 20 minutes following meals: While sitting upright after meals is beneficial for preventing reflux and aspiration, 20 minutes is not sufficient. The client should remain upright for at least 30 minutes after meals to further reduce the risk of aspiration.

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Correct Answer is D

Explanation

a. "I will ask your mother's primary care provider to speak with you."This response does not address the issue of confidentiality and consent. The nurse should not assume that the provider will discuss the treatment without the client's consent.

B.“You will have to speak directly to your mother about her treatment.”This response correctly redirects the child to the client but does not fully explain the importance of consent and confidentiality, which are crucial in maintaining professional and ethical standards.

C.“What would you like to know about your mother’s treatment.”This response might imply a willingness to share information without the client’s consent, which would be a violation of confidentiality and privacy laws.

D.“I cannot provide this information to you without your mother’s consent.”Correct. This response clearly states the need for the client’s consent before any information can be shared, adhering to the principles of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA) regulations.

A. A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness B. A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL C. A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0 to 10 D. A client who is 3 days postoperative following abdominal surgery and is ready for discharge

Correct Answer is A

Explanation

a. A client with Alzheimer's disease and bacterial pneumonia with newly onset restlessness may be experiencing delirium, which could indicate a worsening of their pneumonia or another underlying issue. Delirium can be a sign of a serious medical condition and requires immediate assessment to determine the cause and provide appropriate intervention.

b. While a fasting blood glucose level of 200mg/dL in a newly admitted client with diabetes mellitus is high and requires attention, it is not as urgent as assessing a client with newly onset restlessness, as described in option a.

c. A client who is 24 hours postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 requires assessment and pain management, but it is not as urgent as assessing the client with newly onset restlessness.

d. A client who is 3 days postoperative following abdominal surgery and is ready for discharge may require routine assessment and preparation for discharge, but it is not as urgent as assessing the client with newly onset restlessness.

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A charge nurse is observing a licensed practical nurse assist a client who has dysphagia while eating. Which of the following actions by the LPN should the charge nurse identify as providing safe care?

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