A nurse is planning care for a client who has dysphagia. Which of the following actions should the nurse include in the plan?

Instruct the client to tilt their head forward when swallowing.

Position the client at a 45° angle during mealtime.

Allow 15 minutes for the client's mealtimes.

Encourage the client to use liquids to clear food from the mouth.

Answer and Explanation

The Correct Answer is A

. Instruct the client to tilt their head forward when swallowing: Tilting the head slightly forward, or the “chin-tuck” technique, helps protect the airway during swallowing by narrowing the airway entrance and facilitating safe passage of food and liquids into the esophagus. This method reduces the risk of aspiration, which is a primary concern in clients with dysphagia.

B. Position the client at a 45° angle during mealtime: A 45° angle is insufficient to protect the airway. Clients with dysphagia should be positioned upright at 90° during meals to promote gravity-assisted swallowing and reduce the risk of aspiration pneumonia.

C. Allow 15 minutes for the client's mealtimes: Clients with dysphagia often require more time to safely chew and swallow, and limiting mealtime to only 15 minutes may increase the risk of choking or aspiration. Extended, unrushed feeding is recommended.

D. Encourage the client to use liquids to clear food from the mouth: Thin liquids can increase the risk of aspiration in clients with dysphagia. Instead, small sips of appropriately thickened liquids are safer for clearing the oral cavity and aiding safe swallowing.

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Correct Answer is C

Explanation

A. "Clean the earmold using an alcohol swab.": Alcohol can damage the plastic components of the earmold and may cause cracking or deterioration over time. Proper care involves cleaning the earmold with mild soap and water, then allowing it to dry completely before reattachment. Using alcohol increases the risk of device damage and skin irritation within the ear canal.

B. "Store the hearing aid in a moist environment.": Hearing aids should be kept in a dry environment because moisture can damage the internal electronic components and reduce device lifespan. Many users are advised to store hearing aids in a protective case or a dehumidifier container to prevent humidity-related malfunction.

C. "Turn the hearing aid volume up slowly once inserted.": Gradually increasing the volume allows the client to adjust to amplified sound and prevents discomfort or auditory overstimulation. Sudden loud amplification can be startling and may discourage consistent use. This approach supports safe acclimatization and promotes adherence to hearing aid use.

D. "Increase volume on the hearing aid if whistling occurs.": Whistling (feedback) usually indicates improper fit, earwax buildup, or excessive volume. Increasing the volume can worsen the feedback loop by amplifying sound leakage. The appropriate response is to check fit, reduce volume, or assess for

A. Ensure the client has been NPO for 6 hr. B. Place the client leaning forward over the overbed table. C. Schedule the client for an MRI after the procedure. D. Encourage the client to take deep breaths during the procedure.

Correct Answer is B

Explanation

A. Ensure the client has been NPO for 6 hr: Fasting is not routinely required for a thoracentesis because the procedure does not involve general anesthesia or significant risk of aspiration. NPO status may be indicated only if sedation is planned, but it is not a standard preparation for a diagnostic or therapeutic thoracentesis.

B. Place the client leaning forward over the overbed table: Proper positioning is essential for thoracentesis. Leaning the client forward with arms resting on an overbed table increases intercostal space and stabilizes the chest wall, allowing safe needle insertion into the pleural space. This minimizes the risk of lung puncture and facilitates drainage of pleural fluid.

C. Schedule the client for an MRI after the procedure: An MRI is not a standard follow-up after thoracentesis. Post-procedure care typically includes monitoring vital signs, assessing for pneumothorax, and sometimes obtaining a chest X-ray, but MRI is unnecessary unless another diagnostic indication exists.

D. Encourage the client to take deep breaths during the procedure: Clients are instructed to hold their breath momentarily or breathe slowly and steadily to reduce movement and prevent lung injury. Encouraging deep breaths during needle insertion could increase the risk of puncturing lung tissue and is therefore contraindicated.

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A nurse is planning care for a client who has dysphagia. Which of the following actions should the nurse include in the plan?

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