A nurse is caring for a client who has dysphagia.
Which of the following actions should the nurse take?
Instruct the client to tilt their head back while swallowing.
Elevate the client's head of the bed to 45° during meals.
Alternate the client's liquids and solids during meals.
Encourage the client to lie flat after meals.
The Correct Answer is C
Choice A rationale
Instructing a client with dysphagia to tilt their head back while swallowing can actually increase the risk of aspiration. This position opens the airway and makes it easier for food or liquid to enter the trachea instead of the esophagus, potentially leading to pneumonia or other respiratory complications.
Choice B rationale
Elevating the client's head of the bed to 45° during meals is a crucial intervention for clients with dysphagia. This semi-Fowler's position helps to utilize gravity to facilitate the passage of food and liquids down the esophagus and reduces the risk of aspiration into the airway. Maintaining this upright posture during and shortly after meals is essential for safe swallowing.
Choice C rationale
Alternating liquids and solids during meals can help manage dysphagia by reducing the bolus size and consistency that the client needs to manage at any given time. This strategy can prevent overwhelming the client's swallowing ability and decrease the risk of aspiration by allowing for better control over different food textures.
Choice D rationale
Encouraging the client to lie flat after meals is contraindicated for clients with dysphagia. Lying flat increases the risk of regurgitation and aspiration of food or liquids into the airway. Clients with swallowing difficulties should remain in an upright or semi-upright position for at least 30-60 minutes after eating to allow for proper digestion and reduce the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Dried beans, such as lentils, kidney beans, and chickpeas, are excellent sources of plant-based protein. They contain a significant amount of amino acids, which are the building blocks of protein, making them a valuable addition to a vegetarian toddler's diet to support growth and development.
Choice B rationale
Cooked carrots are primarily a source of vitamins, particularly beta-carotene (a precursor to vitamin A), and fiber. They contain minimal amounts of protein and are not the best choice for increasing dietary protein intake in a vegetarian toddler.
Choice C rationale
Sliced bananas are a good source of carbohydrates, potassium, and some vitamins. However, they are low in protein and would not significantly contribute to increasing the dietary protein intake of a vegetarian toddler.
Choice D rationale
Whole wheat bread contains some protein, but it is not as concentrated a source as dried beans. While whole grains are important for fiber and overall nutrition, dried beans offer a higher protein content per serving, making them a better choice for increasing protein intake.
Correct Answer is ["1.52"]
Explanation
Step 1 is: The physician ordered 500 mg and the available concentration is 330 mg/mL. To find the volume to administer, divide the ordered dose by the available concentration: 500 mg ÷ 330 mg/mL.
Step 2 is: 500 ÷ 330 = 1.5151.
Step 3 is: Round to the nearest hundredth as is common for medication administration: 1.52 mL.
Final answer: The nurse will administer 1.52 mL.
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