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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale:
An elevated white blood cell (WBC) count is an expected manifestation in a client with suspected appendicitis. Inflammation in the appendix leads to an immune response, causing an increase in WBC count.
Choice B rationale:
Elevated amylase level is not typically associated with appendicitis. Elevated amylase is more commonly seen in pancreatitis, not appendicitis.
Choice C rationale:
Rebound tenderness, which refers to increased pain when pressure is released rather than applied, is a classic symptom of appendicitis. The nurse should expect to find rebound tenderness during the abdominal assessment.
Choice D rationale:
Ascites are not a common manifestation of appendicitis. Ascites is the accumulation of fluid in the abdominal cavity and are more commonly seen in liver cirrhosis and certain other conditions, but not in appendicitis.
Choice E rationale:
Anorexia, or loss of appetite, can be seen in clients with appendicitis due to the inflammation and discomfort in the abdominal region.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not cross the client's legs when sitting in the recliner following a total left hip arthroplasty. Crossing the legs can put strain on the operative hip and may increase the risk of dislocation or other complications.
Choice B rationale:
Providing a heating pad to the operative hip is not recommended. Heat can increase blood flow to the area and may lead to increased swelling and potential complications in the postoperative period.
Choice C rationale:
Placing a pillow between the legs when turning the client to their side is the correct action. This technique is known as the "abduction pillow”. or "wedge pillow.”. It helps maintain proper hip alignment and prevents the operated leg from crossing the midline, reducing the risk of dislocation and promoting healing.
Choice D rationale:
Having the client lean forward when assisting them out of the bed is not appropriate after a total left hip arthroplasty. Leaning forward can put strain on the hip joint and increase the risk of injury.
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