A nurse is caring for a client who is at risk for aspiration pneumonia due to dysphagia. Which of the following actions should the nurse take to prevent this complication?
Tell the client to lie down after eating.
Instruct the client to tuck her chin when swallowing.
Place the client in a Fowler's position to eat.
Encourage the client to drink water before each meal.
The Correct Answer is B
Choice A reason: Telling the client to lie down after eating can increase the risk of aspiration pneumonia, as food or liquids can enter the lungs more easily when lying down.
Choice B reason: Instructing the client to tuck her chin when swallowing can help prevent aspiration pneumonia, as it closes off the airway and directs food or liquids into the esophagus.
Choice C reason: Placing the client in a Fowler's position to eat can help prevent aspiration pneumonia, as it elevates the head and chest and allows gravity to assist with swallowing.
Choice D reason: Encouraging the client to drink water before each meal can increase the risk of aspiration pneumonia, as it can thin out saliva and make it harder to control swallowing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hemoglobin 16 g/dL is within the normal range for adults and does not indicate an adverse effect of TPN.
Choice B reason: Temperature 36.1°C (97°F) is normal and does not indicate an infection or inflammation, which are possible complications of TPN.
Choice C reason: Blood glucose 98 mg/dL is normal and does not indicate hyperglycemia or hypoglycemia, which are common problems associated with TPN.
Choice D reason: Weight gain of 1.5 kg (3 lB. per day is excessive and indicates fluid overload, which can result from too rapid or too high infusion of TPN. Fluid overload can cause edema, hypertension, heart failure, and pulmonary congestion.
Correct Answer is D
Explanation
Choice A reason: A pump is usually needed to administer intermittent tube feedings, as it can control the flow rate and volume of the formula. A pump can also prevent overfeeding, aspiration, or diarrhea.
Choice B reason: Administering feedings over 10 to 20 minutes is too fast, as it can cause abdominal cramps, nausea, vomiting, or dumping syndrome. Intermittent tube feedings should be administered over 30 to 60 minutes.
Choice C reason: Administering feedings while sleeping at night is not recommended, as it can increase the risk of aspiration, reflux, or infection. Intermittent tube feedings should be administered during waking hours and with the head of the bed elevated at least 30 degrees.
Choice D reason: Advancing the rate of feedings slowly is advisable, as it can help the body adjust to the formula and prevent intolerance or complications. The rate should be increased gradually until the desired goal is reached.
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