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
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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Related Questions
Correct Answer is C
Explanation
a. "You can ask an AP to teach a simple task to a client."
While assistive personnel may assist with client education under the supervision of a licensed nurse, the primary responsibility for teaching tasks to clients usually rests with licensed healthcare providers.
b. "You should assign tasks you are unfamiliar with to an experienced AP."
Delegating tasks to assistive personnel should be based on their competency and the complexity of the task, not necessarily on the nurse's familiarity with it. It is essential to delegate tasks that the AP is trained and competent to perform.
c. "If you are unsure about an AP’s ability, observe them performing the task."
This is the correct statement. It emphasizes the importance of assessing an assistive personnel's competence by observing their performance before delegating tasks, especially if there is uncertainty about their abilities.
d. "The person who delegates a task is not held accountable for the outcome."
This statement is incorrect. The person delegating a task is ultimately accountable for ensuring that the task is performed correctly and safely. Delegation does not relieve the delegator of accountability.
Correct Answer is B
Explanation
a. "You must choose a member of your family to serve as your health care proxy":
This response is not accurate. While family members are often chosen as healthcare proxies, the client is not required to select a family member. The most important consideration is choosing someone who understands the client's healthcare wishes and is willing and able to advocate for them. The nurse should emphasize the importance of selecting a trusted individual, whether they are a family member or not.
b. "A health care proxy can make decisions for you when you are unable to do so":
This response is accurate. A healthcare proxy is a legal document that allows an individual to appoint someone else to make healthcare decisions on their behalf if they become unable to do so due to illness or incapacity. The nurse should explain the role of a healthcare proxy in advocating for the client's wishes and ensuring that their healthcare preferences are honored.
c. "You should appoint a health care proxy before undergoing an invasive procedure":
While it is advisable for clients to have advance directives, including a healthcare proxy, in place before undergoing any medical procedure, this response does not fully address the client's question. The timing of appointing a healthcare proxy should not be limited to specific medical procedures but should be based on the client's readiness to make such decisions and their recognition of the importance of having a designated advocate for their healthcare needs.
d. "It is necessary for an attorney to approve your health care proxy":
This response is not accurate. While it may be helpful to seek legal advice when creating advance directives, including a healthcare proxy, it is not a requirement for an attorney to approve the document. The client can typically complete a healthcare proxy form themselves, following the legal requirements of their jurisdiction. However, consulting with an attorney can provide additional guidance and ensure that the document is properly executed.
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