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 C

Explanation

A. A newborn has respiratory distress and requires oxygen: This is a clinical event requiring immediate intervention but not necessarily an error or unexpected event warranting an incident report.
B. A newborn has an Apgar score of 7 at 5 minutes after birth: An Apgar score of 7 is within a normal range and does not constitute an unusual or reportable incident.
C. A newborn receives erythromycin ophthalmic ointment 4 hours after birth: Erythromycin should be administered within 1 to 2 hours after birth to prevent neonatal eye infections. Delayed administration requires incident reporting.
D. A newborn receives a heel stick on the outer aspect of the heel: This is standard practice to prevent nerve and tissue damage during blood sampling and does not require an incident report.

A. "Have you tried holding your infant skin-to-skin?" B. "Have you considered joining a parents' support group?" C. "What is your infant's level of activity?" D. "Is your infant able to latch on during breastfeeding?"

Correct Answer is D

Explanation

A. "Have you tried holding your infant skin-to-skin?": Important for bonding and soothing but not the priority for postoperative care.
B. "Have you considered joining a parents' support group?": Beneficial for emotional support but not immediately essential for the infant's recovery.
C. "What is your infant's level of activity?": Relevant for assessing overall recovery but not the most critical issue.
D. "Is your infant able to latch on during breastfeeding?" Feeding is the priority concern after cleft palate repair to ensure adequate nutrition and assess for complications.

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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 in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

Correct Answer is C

Explanation

A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

Correct Answer is D

Explanation

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