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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Sublingual medications are designed to be absorbed directly into the bloodstream through the highly vascular mucous membranes under the tongue. Dissolving it in water and administering it through an NG tube would bypass this route, potentially altering the drug's absorption and effectiveness, as it would then be processed through the gastrointestinal system.

Choice B rationale

Administering the medication under the client's tongue ensures that it is absorbed sublingually, bypassing the gastrointestinal tract. This is the intended route for this medication, allowing for rapid absorption and avoiding potential interactions or degradation in the digestive system. The rich blood supply under the tongue facilitates quick entry into systemic circulation.

Choice C rationale

Requesting an oral formulation might be an option if the sublingual route is absolutely contraindicated, but it doesn't address the immediate situation. Oral medications have different absorption rates and may be unsuitable for a client with an NG tube if they have swallowing difficulties or other gastrointestinal issues.

Choice D rationale

Crushing a sublingual medication and administering it through an NG tube is inappropriate. This alters the intended drug delivery mechanism and could lead to unpredictable absorption, potential blockage of the NG tube, and loss of the medication's intended effect. Sublingual formulations are not designed for enteral administration.

Correct Answer is ["200"]

Explanation

Step 1 is: The total volume to be infused is 50 mL.

Step 2 is: The infusion time is 15 minutes.

Step 3 is: To find the milliliters per hour, first convert minutes to hours: 15 minutes ÷ 60 minutes/hour = 0.25 hours.

Step 4 is: Calculate the infusion rate in mL/hour: 50 mL ÷ 0.25 hours = 200 mL/hour. The nurse will infuse the drug at 200 mL per hour.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 provider prescribes a sublingual medication for a client who has an nasogastric (NG) tube in place.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The MD orders a pre-op patient to have Kefzol 1g to be infused over 15 minutes. The Kefzol is diluted in 50 mL of D5W. How many milliliters per hour will the nurse infuse the drug?

Correct Answer is ["200"]

Explanation

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

When providing information about elevated cholesterol levels, the nurse explains that saturated fats usually are animal in origin, solid at room temperature, and should be avoided because they:

A clinical instructor is reviewing the abdominal assessment with a group of students.She would include which of the following three percussion sounds the nurse would expect to hear? (Select 3 options)

A nurse is contributing to the plan of care of a client who is in a long-term care facility.To improve the client's nutritional status, which of the following nursing interventions should the nurse recommend adding to the plan? Provide soft foods.

A nurse is conducting a class on BSE.Which statement indicates the proper BSE technique?

During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast.Which of these statements is true about this finding?

A nurse inspects the abdomen for skin color, contour, surface characteristics, and symmetry.What part of the abdominal assessment does the nurse perform next?

The nurse is assessing a patient's bowel sounds.The nurse does not hear anything for 30 seconds.How should the nurse document this finding?

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