A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?

Elevate the head of the client's bed to 45" during meals.

Request a speech therapist consult from the provider.

Instruct the client to tilt their head back when swallowing.

Administer liquids to the client using a syringe.

Answer and Explanation

The Correct Answer is B

A.   Elevate the head of the client's bed to 45° during meals: The head should be elevated to 90° to reduce the risk of aspiration during meals.
B.   Request a speech therapist consult from the provider: Speech therapists can assess swallowing difficulties and recommend appropriate strategies.
C.   Instruct the client to tilt their head back when swallowing: This position increases the risk of aspiration by opening the airway during swallowing.
D.   Administer liquids to the client using a syringe: Syringe administration can lead to choking or aspiration and is not a standard feeding practice for dysphagia clients.

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Correct Answer is ["A","B","C","D"]

Explanation

A. The medication administration record indicates the client received pain medication 12 hr ago. This is important to prevent overmedication and assess if the dosing schedule allows another administration.
B. The client reports a pain level of 7 on a scale from 0 to 10. Pain rating is a critical factor in deciding whether to administer PRN pain medication.
C. The client's pulse rate and blood pressure have decreased. Vital sign changes may indicate sedation or hemodynamic instability, which could contraindicate additional pain medication.
D. The client is restless and grimaces with movement. Nonverbal cues of pain are essential considerations, especially if the client is unable to communicate effectively.
E. The client's family tells the nurse the client is in pain. While family input can be valuable, pain assessment should be based on the client's report or nurse observations.

A. Asking a staff member from another unit to complete the evaluation B. Linking the evaluation to predetermined standards C. Focusing primarily on areas that need improvement D. Discussing the evaluation with the nurse manager

Correct Answer is B

Explanation

A. Asking a staff member from another unit to complete the evaluation: Staff from other units may not have direct knowledge of the nurse's work performance.
B. Linking the evaluation to predetermined standards: Using predetermined standards ensures objectivity and consistency in evaluations.
C. Focusing primarily on areas that need improvement: Evaluations should be balanced, recognizing both strengths and areas for improvement.
D. Discussing the evaluation with the nurse manager: The evaluation should first be completed independently before discussing it with a manager if needed.

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A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is postoperative. Which of the following findings should the nurse consider before administering the prescribed PRN pain medication? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is B

Explanation

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