A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to reduce the risk of aspiration?

Have the client point their chin upward to swallow.

Offer the client saltine crackers between meals.

Thicken liquids before serving.

Place food on the affected side of the mouth.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Having the client point their chin upward to swallow is not a recommended action to reduce the risk of aspiration. In fact, this action can increase the risk of choking and aspiration, as it may cause food or liquids to enter the airway.
Choice B rationale:
Offering the client saltine crackers between meals is not a suitable action for reducing the risk of aspiration. Saltine crackers are dry and can be challenging to swallow for someone with dysphagia, potentially increasing the risk of aspiration.
Choice C rationale:
Thicken liquids before serving is the correct action to reduce the risk of aspiration in a client with dysphagia. Thickened liquids are easier to swallow and less likely to enter the airway, reducing the risk of aspiration pneumonia.
Choice D rationale:
Placing food on the affected side of the mouth does not address the risk of aspiration directly. Dysphagia may affect both sides of the mouth, and placing food on one side does not ensure safe swallowing and reduces the effectiveness of addressing the problem.

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Correct Answer is C

Explanation

Choice A rationale:

Preparing an endotracheal tube for intubation is not the first action the nurse should take in this situation. Intubation is an invasive procedure and should be reserved for cases where other, less invasive methods of airway management have failed.

Choice B rationale:

Inserting a plastic oral airway may help maintain the airway in some situations, but it is not the first action to take when the client's airway is obstructing and their oxygen saturation is low.

Choice C rationale:

Providing oxygen using a manual resuscitation bag (bag-valve-mask device) is the correct first action. This allows the nurse to manually assist the client's breathing and deliver oxygen more effectively than just providing supplemental oxygen through a nasal cannula or face mask.

Choice D rationale:

Performing a head tilt with a chin-lift is a basic airway maneuver, but it may not be sufficient in this situation, especially if the airway is completely obstructed. Providing oxygen with a manual resuscitation bag takes precedence.

A. "I will wear gloves when I change my cat's litter box.". B. "I will take my temperature once each week.". C. "I will be able to attend my favorite singer's concert.". D. "I will allow my toothbrush to dry completely between each use.".

Correct Answer is A

Explanation

Choice A rationale:
Wearing gloves when changing the cat's litter box is essential during chemotherapy because some chemotherapy drugs can be excreted in bodily fluids, including feces. Protecting against direct contact with potentially harmful substances is crucial to minimize exposure risks.
Choice B rationale:
Taking the temperature once each week is not a relevant precaution during chemotherapy. Monitoring temperature is important, but it should be done more frequently, such as daily, as chemotherapy can cause immunosuppression, increasing the risk of infection.
Choice C rationale:
Being able to attend a concert is not related to precautions during chemotherapy. It is essential for clients undergoing chemotherapy to avoid large gatherings and events where they might be exposed to infections.
Choice D rationale:
Allowing the toothbrush to dry completely between each use is a good hygiene practice but not specifically related to chemotherapy precautions. Proper oral hygiene is essential during chemotherapy, but using a soft toothbrush and regularly replacing it are more relevant considerations.

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A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to reduce the risk of aspiration?

Nursing Test Bank

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