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 ["1"]
Explanation
The correct answer is 1 mL.
Step 1 is: Examine the medication label to determine the concentration of epoetin. The label indicates a concentration of 30,000 units per 1 mL.
Step 2 is: Set up the calculation to find the volume needed by dividing the ordered dose by the concentration: 30,000 units ÷ (30,000 units/mL).
Step 3 is: Perform the division: 30,000 ÷ 30,000 = 1.
Step 4 is: The units cancel out, leaving the volume in milliliters: 1 mL. Final answer is 1 mL.
Correct Answer is A
Explanation
Choice A rationale
Abrupt cessation of total parenteral nutrition (TPN) can lead to a rapid decrease in blood glucose levels. While receiving TPN, the body is continuously supplied with glucose. When this external glucose source is suddenly removed, the pancreas may continue to secrete insulin at a rate higher than needed, resulting in hypoglycemia. Signs and symptoms of hypoglycemia include sweating, tremors, confusion, and dizziness.
Choice B rationale
Hyperthermia, or elevated body temperature above the normal range of approximately 36.5°C to 37.5°C (97.7°F to 99.5°F), is not a typical complication following the discontinuation of TPN. Fever is usually associated with infection or inflammation, neither of which are a direct consequence of stopping TPN.
Choice C rationale
Flatulence, or the accumulation of gas in the digestive tract leading to bloating and the passage of gas, is related to dietary intake and digestive processes. Discontinuing TPN, which bypasses the digestive system, would not directly cause an increase in flatulence. In fact, digestive issues might improve once oral or enteral feeding resumes.
Choice D rationale
Tachycardia, an abnormally rapid heart rate (typically defined as above 100 beats per minute in adults), is not a direct physiological consequence of discontinuing TPN. While changes in fluid balance or electrolyte levels (which can occur with TPN but are monitored closely) could indirectly affect heart rate, hypoglycemia is a more immediate and direct risk upon TPN cessation.
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