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.

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Correct Answer is A

Explanation

Choice A rationale

Palpating the unaffected breast first establishes a baseline for what is normal for the patient. This allows the nurse to then compare any findings on the affected breast, where the patient has noted a lump, to the patient's normal breast tissue. This comparative approach aids in identifying any true abnormalities.

Choice B rationale

Palpating the breast with the lump first could introduce anxiety and may make it more difficult to thoroughly assess the unaffected breast due to the patient's potential apprehension. While axillary lymph node assessment is crucial, delaying it slightly after the initial breast examination allows for a more systematic approach.

Choice C rationale

Avoiding palpation of a newly discovered lump is inappropriate nursing practice. A new lump warrants investigation to determine its nature. Palpation is a key component of the physical examination and helps to assess the size, shape, consistency, and mobility of the lump, providing essential information for further evaluation.

Choice D rationale

Palpating the lump first, without establishing a baseline on the unaffected breast, makes it harder to determine if the finding is truly new or abnormal for this specific patient. Comparing findings to the contralateral breast is a standard technique in breast examination to identify deviations from the norm.

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.

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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 patient states during the interview that she noticed a new lump in the shower a few days ago.It was on her left breast near her axilla.How should the nurse proceed?

Correct Answer is A

Explanation

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Correct Answer is ["1"]

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