A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching?
Give the client a straw to use for drinking.
Place oral suction equipment next to the client's bedside.
Provide thin liquids to help the client swallow.
Use a needleless syringe to instill feedings.
The Correct Answer is B
A. "Give the client a straw to use for drinking" is incorrect. Straws are not recommended for clients with dysphagia because they can increase the risk of aspiration. It is better to use a cup to control the amount of liquid ingested and reduce choking risk.
B. "Place oral suction equipment next to the client's bedside" is correct. For clients with dysphagia, having oral suction equipment readily available can help clear the airway quickly in case of aspiration or choking. It is an important safety measure in the management of dysphagia.
C. "Provide thin liquids to help the client swallow" is incorrect. Thin liquids can increase the risk of aspiration for clients with dysphagia. It is often recommended to provide thickened liquids, as they are easier to swallow and less likely to be aspirated.
D. "Use a needleless syringe to instill feedings" is incorrect. The use of a needleless syringe for feeding is generally not appropriate for clients with dysphagia unless specifically recommended for feeding via a tube. Otherwise, feeding should be done carefully with consideration for the type and consistency of the food.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I can prevent nausea if I take the medication on an empty stomach." This is incorrect. Taking ferrous sulfate on an empty stomach may increase the risk of gastrointestinal upset, including nausea. It is typically recommended to take it with food to reduce these side effects, although it may be less effective if taken with certain foods or beverages.
B. "I can prevent constipation if I drink more milk while taking this medication." This is incorrect. Milk can actually worsen constipation, and clients taking ferrous sulfate should focus on increasing fiber intake and drinking plenty of fluids to prevent constipation.
C. "I will report black stools to my doctor." This is correct. Black stools are a common side effect of iron supplementation, but it is essential for the client to report it to the doctor if they are concerned, as it could also indicate gastrointestinal bleeding in some cases.
D. "I will mix the medication with a full glass of water." While taking the medication with a full glass of water is appropriate, it is not the most significant instruction regarding the use of the medication. Therefore, while the answer isn't wrong, it doesn't indicate the client's understanding of the most important aspects, such as monitoring for side effects like black stools.
Correct Answer is B
Explanation
A. The client's potassium level is 2.7 mEq/L is incorrect. A potassium level of 2.7 mEq/L is low and indicates hypokalemia, which is a life-threatening condition that can occur in anorexia nervosa, particularly if the client is engaging in behaviors like purging. This level should be addressed immediately, not considered a positive outcome.
B. The client resumes menstruation is correct. The resumption of menstruation is a positive outcome of treatment for anorexia nervosa. It indicates that the client's nutritional status has improved and that the body is starting to regain normal function after addressing issues like malnutrition and hormonal imbalances.
C. The client's pulse rate is 44/min is incorrect. A pulse rate of 44/min is bradycardia, which is a common sign of anorexia nervosa due to malnutrition and the body's attempt to conserve energy. While it may improve with treatment, this finding would not be considered a positive outcome.
D. The client develops lanugo is incorrect. Lanugo (fine, soft hair) typically develops in severe anorexia nervosa due to malnutrition and is a sign of starvation. The appearance of lanugo is not a positive outcome but rather a compensatory mechanism to retain heat, indicating that the client is still in a malnourished state.
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