A nurse is reviewing the prescriptions for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

Speech therapy referral

Dietitian consult

Oral suction at the bedside

Clear liquids

Answer and Explanation

The Correct Answer is D

A. Speech therapy referral: A speech therapy referral is appropriate for a client with dysphagia following a stroke. Speech therapists can assess the severity of swallowing difficulties and provide strategies to improve swallowing function. This is standard care.

B. Dietitian consult: A dietitian consult is essential to ensure proper nutritional intake and modify the client's diet for safe swallowing. A dietitian can help adjust the texture of foods and recommend alternatives to reduce the risk of aspiration.

C. Oral suction at the bedside: Oral suctioning is a precautionary measure for clients with dysphagia to clear any potential obstructions from the airway. It’s essential to have suction equipment available at the bedside in case of choking or aspiration.

D. Clear liquids: Clear liquids are not recommended for clients with dysphagia because they pose a higher risk for aspiration. Clear liquids can be difficult for individuals with swallowing difficulties to control and may lead to choking or aspiration pneumonia.

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Correct Answer is C

Explanation

A. Add water during tube flushes: Adding water during tube flushes is important for maintaining tube patency and hydration but does not directly address diarrhea. It is not a primary solution for managing diarrhea caused by enteral feedings.

B. Change to an enteral formula that has added fiber: While fiber can help regulate bowel movements, changing to a formula with added fiber is not the first intervention for diarrhea. A slow-down of the feeding rate may be more effective to allow the digestive system more time to process the formula.

C. Slow down the instillation flow rate: Slowing down the flow rate of the enteral feeding can reduce the likelihood of diarrhea. A rapid infusion rate can overwhelm the intestines and lead to diarrhea, so adjusting the flow rate is an appropriate first step.

D. Add yogurt to enteral feedings: While yogurt contains probiotics that might help with gut health, adding it to the feeding may not be advisable unless specifically indicated. The primary step for managing diarrhea is adjusting the flow rate of the feeding.

A. Make a priority list of information the client should learn. B. Determine the client's learning needs. C. Obtain written information to give the client. D. Select a visual method to reinforce verbal teaching for the client.

Correct Answer is B

Explanation

A. Make a priority list of information the client should learn: While making a priority list of information is important, it should come after assessing the client's learning needs. This ensures that the most relevant and important information is prioritized.

B. Determine the client's learning needs: The first step in planning teaching is to assess the client’s learning needs. This allows the nurse to tailor the teaching plan to the client’s level of understanding, cultural preferences, and specific concerns related to the central venous access device.

C. Obtain written information to give the client: Written information is helpful but should not be the first step. It is more effective when tailored to the client’s learning needs, which should be assessed first to ensure relevance.

D. Select a visual method to reinforce verbal teaching for the client: Visual methods can be helpful for reinforcing verbal teaching, but this step should follow the assessment of the client’s learning needs. Teaching strategy should align with the client’s preferred learning style.

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A nurse is reviewing the prescriptions for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving enteral feedings through a nasogastric tube and has developed diarrhea. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is planning teaching for a client who will be discharged with a central venous access device. Which of the following actions should the nurse plan to take first?

Correct Answer is B

Explanation

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