A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?

Initiate a calorie count of daily food intake.

Provide food in a thin liquid consistency.

Instruct the client to keep their chin up when swallowing.

Place the client in a semi-Fowler's position when eating.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Initiating a calorie count of daily food intake is not directly related to addressing dysphagia. Calorie counts might be important in certain situations, such as managing weight, but it does not directly address the client's swallowing difficulties.
Choice B rationale:
Providing food in a thin liquid consistency is contraindicated for a client with dysphagia. Thin liquids can increase the risk of aspiration in individuals with swallowing difficulties. The nurse should choose thicker liquids and modify the diet as recommended by a speech-language pathologist or healthcare provider.
Choice C rationale:
Instructing the client to keep their chin up when swallowing is not an appropriate action for addressing dysphagia. Instead, clients with dysphagia are often instructed to tuck their chin down to their chest when swallowing. This helps to close off the airway and prevents food or liquids from entering the airway.
Choice D rationale:
Placing the client in a semi-Fowler's position when eating is the correct action. This position helps prevent aspiration by promoting proper alignment of the airway and esophagus. The semi-Fowler's position involves elevating the head of the bed to an angle of 30-45 degrees. This position facilitates swallowing and reduces the risk of choking or aspiration.

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Correct Answer is B

Explanation

Choice A rationale:

Stopping caffeinated beverages is a positive step in managing gastroesophageal reflux disease (GERD) as caffeine can exacerbate symptoms by relaxing the lower esophageal sphincter (LES). However, this choice is not the best-contributing factor to GERD among the options provided.

Choice B rationale:

Correct Choice. Drinking warm milk before bed is a contributing factor to GERD. Milk is slightly acidic and can increase gastric acid production, potentially leading to reflux symptoms. It is important for individuals with GERD to avoid foods or drinks that can relax the LES or increase gastric acid production.

Choice C rationale:

Stopping alcohol consumption is generally beneficial for managing GERD, as alcohol can relax the LES and increase stomach acid production. However, among the choices, this is not the most relevant contributing factor to GERD.

Choice D rationale:

Following a low-fat, high-protein diet is generally recommended for managing weight and promoting overall health. While it is beneficial for weight management, it is not a key contributing factor to GERD symptoms, especially when compared to other choices like drinking warm milk before bed.

A. Obtain the client's electrolyte levels every 4 hr. B. Measure the client's gastric residual every 12 hr. C. Keep the client's head elevated at 15 during feedings. D. Flush the client's tube with 30 mL of water every 4 hr.

Correct Answer is B

Explanation

Choice A rationale:
Obtaining the client's electrolyte levels every 4 hours is not standard practice when initiating continuous enteral feedings via a gastrostomy tube. While monitoring electrolytes is important, it's not done at such a high frequency unless there's a specific indication or concern.
Choice B rationale:
Measuring the client's gastric residual every 12 hours is a crucial action when initiating continuous enteral feedings. Gastric residual volume helps to assess the client's tolerance to the feeding, the rate of digestion and absorption, and the risk of aspiration. If the residual volume is too high, it could indicate feeding intolerance or delayed gastric emptying.

Choice Crationale:
Keeping the client's head elevated at 15 degrees during feedings is not standard practice for continuous enteral feedings. This angle could potentially promote reflux and increase the risk of aspiration. Instead, the head of the bed is usually elevated at least 30 degrees to help prevent reflux and aspiration.

Choice Drationale:
Flushing the client's tube with 30 mL of water every 4 hours is not a standard practice for continuous enteral feedings. Flushing the tube helps maintain its patency, but it's usually done before and after medication administration or as needed to prevent clogs, not on such a frequent schedule.

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A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports manifestations of gastroesophageal reflux disease (GERD). Which of the following client statements should the nurse identify as a contributing factor to GERD?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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