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. Assault:

Assault involves the threat of bodily harm or unwanted physical contact that creates fear or apprehension in the victim. In this scenario, there is no indication of a threat being made against the client; instead, the nurse administers the medication without their consent.

b. Libel:

Libel refers to a false written statement that damages a person's reputation. This option is not applicable to the scenario described, as it does not involve written communication or defamation of character.

c. Battery:

Battery occurs when there is unauthorized physical contact with another person that results in harm or offense. In this scenario, the nurse administers the injection against the client's will, which constitutes unauthorized physical contact, making it an example of battery.

d. False imprisonment:

False imprisonment involves unlawfully restraining or confining a person against their will. While administering medication without consent could potentially be perceived as a form of restraint, false imprisonment typically involves physical confinement or restriction of movement, which is not the case in this scenario.

A. Instruct the AP to request assistance when unsure about a task B. Demonstrate the proper client transfer technique for the AP C. Help the AP assist the client with the transfer D. Refer the AP to the facility procedure manual

Correct Answer is C

Explanation

a. Help the AP assist the client with the transfer.

While it is important to instruct the AP to seek assistance when unsure, this does not immediately address the safety of the client during the current incorrect transfer.

b. Demonstrate the proper client transfer technique to the AP.

Demonstrating the proper technique is an important step, but it should come after ensuring the immediate safety of the client. This can be done once the client is safely transferred.

c. Instruct the AP to request assistance when unsure about a task.

Correct. The nurse's first priority should be the safety of the client. By immediately assisting the AP with the transfer, the nurse ensures the client's safety and prevents potential injury.

d. Refer the AP to the facility procedure manual.

Referring the AP to the procedure manual is important for future reference, but it does not address the immediate risk to the client. This action can be taken after ensuring the client's safety and demonstrating the correct technique.

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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?

Nursing Test Bank

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