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 A

Explanation

a. Transport the client to the operating room without verifying informed consent:

This option suggests an urgent response, prioritizing the immediate need for surgery over the formal process of obtaining informed consent. In certain emergency situations, such as when a patient's life or health is in imminent danger and obtaining consent is not feasible, healthcare providers may proceed with treatment or surgery to prevent further harm or loss of life. However, this approach should be guided by established protocols, legal considerations, and the principle of providing the best possible care for the patient.

b. Delay the surgery until the nurse can obtain informed consent:

This option advocates for ensuring that the patient's autonomy and rights are respected by obtaining informed consent before proceeding with surgery. While obtaining consent is essential, delaying surgery may not always be feasible or advisable in emergency situations where prompt intervention is necessary to prevent deterioration of the patient's condition. However, if circumstances allow, making efforts to obtain informed consent is ethically and legally preferable.

c. Obtain telephone consent from the facility administrator before the surgery:

This option proposes seeking consent from a designated authority within the healthcare facility, such as a facility administrator, via telephone. While this approach may be practical in some cases, it may not always be sufficient to ensure that the patient's rights are fully respected, particularly if the administrator does not have the legal authority to provide consent on behalf of the patient. In emergency situations, obtaining consent from a legally authorized representative of the patient, if available, is generally preferred.

d. Ask the anesthesiologist to sign the consent:

This option involves delegating the responsibility of signing the consent form to another member of the healthcare team, in this case, the anesthesiologist. However, consent for surgery should ideally be obtained directly from the patient or their legally authorized representative, as they are the ones who have the right to make decisions about their medical care. Relying on another healthcare provider to sign the consent form may not adequately protect the patient's autonomy and legal rights.

A. Green B. Yellow C. Black D. Red

Correct Answer is C

Explanation

a. Green:

Green triage tags are typically used for "walking wounded" or patients with minor injuries who can wait longer for treatment. These patients are considered to have non-life-threatening injuries and can be managed after more critical patients have been stabilized.

b. Yellow:

Yellow triage tags are used for patients with moderate injuries who require medical attention but are not in immediate danger of death. These patients may have significant injuries that require timely treatment but do not have life-threatening conditions.

c. Black:

The black tag is used for patients who are not expected to survive due to severe injuries or critical conditions. In the case of full-thickness burns covering a large percentage of the body (such as 72%), the patient’s prognosis is poor, and immediate care resources should be allocated to those with a higher chance of survival.The black tag indicates that the patient’s injuries are incompatible with life, and comfort measures may be provided, but resuscitation efforts are not a priority.

d. Red:

Red triage tags are used for patients with life-threatening injuries who require immediate medical attention to survive. These patients have critical conditions that require rapid assessment, stabilization, and treatment to prevent further deterioration and improve outcomes.

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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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Correct Answer is A

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