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 ["C"]

Explanation

a. The AP wears a surgical mask when caring for a client who has respiratory tuberculosis.

Incorrect. AP should wear an N95 Maskwhen caring for a client with respiratory tuberculosis helps prevent the spread of airborne pathogens, protecting both the healthcare worker and others in the environment.

b. The AP uses alcohol-based hand sanitizer after emptying the bedpan of a client who has Clostridium difficile.

This action is incorrect. Alcohol-based hand sanitizers are not effective against the spores of Clostridium difficile. Handwashing with soap and water is necessary to effectively remove the spores.

c. The AP bundles the client side of linen inward when changing the sheets for a client who has an infected surgical wound.

When handling soiled linen, it is essential to fold the client side of the linen inward to minimize the spread of contaminants. This helps to ensure that any contaminated surfaces do not come into contact with other surfaces, which is crucial for preventing the spread of infection.

d. The AP removes her gloves before leaving the room of a client who has MRSA.

For MRSA (Methicillin-resistant Staphylococcus aureus), the AP should remove gloves and perform hand hygiene before leaving the room.

A. Providing a 10 min rest period prior to meals B. Elevating the head of the client’s bed to 30 degrees during mealtime C. Instructing the client to place her chin toward her chest when swallowing D. Withholding fluids until the end of the meal

Correct Answer is C

Explanation

a. Providing a 10-minute rest period prior to meals:

This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.

b. Elevating the head of the client’s bed to 30 degrees during mealtime:

The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.

c. Instructing the client to place her chin toward her chest when swallowing:

This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.

d. Withholding fluids until the end of the meal:

Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.

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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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