A nurse is caring for a client who has dysphagia following a stroke.
When assisting the client at mealtime, which of the following actions should the nurse plan to take?

Instruct the client to tilt their head back to facilitate swallowing.

Schedule physical therapy directly before meals.

Provide oral care before meals.

Encourage the client to use a straw.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Instructing the client to tilt their head back increases the risk of aspiration by misaligning the airway and esophagus. Clients with dysphagia require strategies that minimize the risk of aspiration and promote safe swallowing, such as a neutral head position or chin tuck.

Choice B rationale

Scheduling physical therapy directly before meals is inappropriate as it may cause fatigue, reducing the client’s ability to eat safely. Proper scheduling ensures clients have sufficient energy to focus on eating, essential for minimizing aspiration risks in those with dysphagia.

Choice C rationale

Providing oral care before meals reduces the bacterial load in the oral cavity, lowering the risk of aspiration pneumonia if food or liquids are accidentally aspirated. Maintaining good oral hygiene is a key preventive measure for complications related to dysphagia.

Choice D rationale

Encouraging the use of a straw is contraindicated as it can increase the risk of aspiration. Using a straw can direct liquids forcefully to the throat, overwhelming the client’s ability to control swallowing, which is a safety concern for individuals with dysphagia.

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Correct Answer is D

Explanation

Choice A rationale

Removing personal protective equipment outside the client’s room increases the risk of environmental contamination with pathogens. Contact precautions require careful containment of contaminants within the room to prevent the spread of infectious agents to other areas of the healthcare facility, thus making this action inappropriate.

Choice B rationale

An N95 mask is not required for contact precautions but is designated for airborne precautions, such as for tuberculosis or measles. Contact precautions focus on minimizing the spread of infections via touch or contact with bodily fluids, requiring gowns and gloves rather than high-filtration masks.

Choice C rationale

Using an alcohol swab to clean the temperature probe before removing it from the room may not eliminate all pathogens. Probes that contact mucous membranes or bodily fluids should undergo high-level disinfection or sterilization. Ensuring single-patient use of equipment is more effective in preventing cross-contamination in this context.

Choice D rationale

Assigning a dedicated stethoscope for the client during their hospital stay minimizes the risk of transmitting pathogens to other clients. Equipment designated for single-client use remains in the client’s room, reducing the chance of contamination and maintaining infection control measures effectively, aligning with best practices for contact precautions.

A. Dextrose 5% in 0.45% sodium chloride. B. Lactated Ringer’s. C. 0.9% sodium chloride. D. Dextrose 5% in water. E. None F. None

Correct Answer is C

Explanation

Choice A rationale

Dextrose 5% in 0.45% sodium chloride is hypotonic and inappropriate for transfusing packed RBCs, as it can cause hemolysis due to the lower osmolarity of the solution compared to the intracellular environment of the RBCs.

Choice B rationale

Lactated Ringer’s contains calcium, which can chelate with the citrate in stored blood, leading to clots in the transfusion line. This makes it unsuitable for use as an intravenous solution for packed RBCs.

Choice C rationale

0.9% sodium chloride is isotonic and compatible with packed RBCs. It preserves the integrity of RBCs during transfusion, ensuring that no hemolysis or clotting occurs due to interaction with the solution.

Choice D rationale

Dextrose 5% in water is hypotonic and unsuitable for transfusion of packed RBCs, as it can cause hemolysis. The low osmolarity of this solution compromises the cell membrane of the erythrocytes, leading to their destruction. .

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A nurse is caring for a client who has dysphagia following a stroke.When assisting the client at mealtime, which of the following actions should the nurse plan to take?

Nursing Test Bank

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Correct Answer is D

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A nurse is caring for a client who has dysphagia following a stroke.
When assisting the client at mealtime, which of the following actions should the nurse plan to take?