A nurse is caring for a client who had a stroke and is drooling. Which of the following actions should the nurse take first?

Offer the client thickened liquids to drink.

Monitor the client for indications of fatigue during meals.

Check the client's gag reflex.

Monitor the client's ability to speak consistently.

Answer and Explanation

The Correct Answer is C

A. Offer the client thickened liquids to drink: Offering thickened liquids can help reduce the risk of aspiration in clients with dysphagia, which is common after a stroke. However, this should be done after confirming that the client has a safe swallowing mechanism, such as an intact gag reflex. Administering liquids before assessing swallowing safety can increase the risk of aspiration pneumonia.
B. Monitor the client for indications of fatigue during meals: Fatigue can compromise the client’s ability to chew and swallow effectively, increasing the risk of aspiration. Monitoring for this is important but is not the immediate priority when the client is already drooling, a sign that they may be unable to manage their oral secretions. Ensuring safe swallowing should be addressed before monitoring meal-time fatigue.
C. Check the client's gag reflex: Checking the gag reflex is the most important initial action because it directly assesses the client’s ability to swallow safely. Drooling after a stroke often indicates impaired neuromuscular control, which puts the client at high risk for aspiration. The gag reflex gives immediate information on whether oral intake is safe.
D. Monitor the client's ability to speak consistently: Monitoring speech consistency can provide insights into neurological recovery and motor control, but it is not the first concern in a drooling stroke patient. The primary danger is aspiration due to impaired swallowing. Speaking ability does not directly reflect swallowing safety.

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Correct Answer is A

Explanation

A. Record between-meal snacks on the calorie count form: Between-meal snacks contribute significantly to a client's total daily caloric intake and must be included to obtain an accurate calorie count. Omitting these snacks can result in an incomplete dietary assessment, potentially leading to inaccurate evaluations of the client's nutritional status.
B. Begin the calorie count with the client's next evening meal: Calorie counts should begin as soon as the prescription is initiated, not delayed until a specific mealtime. Waiting to begin with the evening meal may result in missed intake data and reduce the accuracy of the assessment. Timely initiation ensures the healthcare team captures a complete and accurate picture of the client’s intake patterns.
C. Exclude liquids in the total calorie count: Liquids, especially those containing calories such as juice, milk, nutritional supplements, or sweetened beverages, must be included in a calorie count. Excluding these items can underestimate the client’s actual caloric intake and interfere with proper evaluation and planning of their nutritional needs.
D. Complete the calorie count for a 5-day period: A standard calorie count is typically conducted over a 72-hour (3-day) period, which is sufficient to identify trends and provide nutritional insights. Extending the count unnecessarily to 5 days may not yield additional useful data and can burden both clients and staff. The focus should be on consistency and completeness within the accepted timeframe.

A. Feedings should begin within 1 hr after birth. B. Feedings can be controlled by gravity. C. Feedings should be on demand. D. Feedings may occur in clusters.

Correct Answer is A

Explanation

A. Feedings should begin within 1 hr after birth. Initiating feeding within the first hour of life supports early bonding and helps stabilize the newborn’s blood glucose. This applies to both breastfed and bottle-fed infants and is considered a key component of newborn care.
B. Feedings can be controlled by gravity. Bottle feedings should not rely solely on gravity, as this can increase the risk of overfeeding and aspiration. Instead, caregivers should hold the bottle at an angle and watch for feeding cues, allowing the infant to suck and swallow at their own pace.
C. Feedings should be on demand. While on-demand feeding is typically encouraged with breastfeeding, bottle feeding is generally guided by scheduled intervals (e.g., every 3–4 hours) early on. Over time, bottle-fed infants may show hunger cues, but structured timing helps regulate intake initially.
D. Feedings may occur in clusters. Cluster feeding is common with breastfeeding due to variable milk flow and infant comfort needs. Bottle-fed infants usually have more consistent feeding patterns and are less likely to feed in unpredictable clusters.

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