A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

Withholding fluids until the end of the meal

Elevating the head of the client's bed to 30 degrees during mealtime

Providing a 10-minute rest period prior to meals

Instructing the client to place her chin toward her chest when swallowing

Answer and Explanation

The Correct Answer is D

Choice A reason: This is not a correct technique for feeding a client who has dysphagia. Withholding fluids until the end of the meal can increase the risk of dehydration and aspiration. Fluids should be offered throughout the meal to help moisten and thin the food.

Choice B reason: This is not a correct technique for feeding a client who has dysphagia. Elevating the head of the client's bed to 30 degrees during mealtime is not enough to prevent aspiration. The client should be in an upright position, preferably at 90 degrees, to facilitate swallowing and gravity.

Choice C reason: This is not a correct technique for feeding a client who has dysphagia. Providing a 10-minute rest period prior to meals is not necessary and may delay the feeding. The client should be fed when they are alert and hungry, and not too tired or sleepy.

Choice D reason: This is a correct technique for feeding a client who has dysphagia. Instructing the client to place her chin toward her chest when swallowing can help close the airway and prevent food from entering the lungs. This can reduce the risk of aspiration and choking.

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Correct Answer is D

Explanation

Choice A reason: This is not the correct choice because witnessing the client signing the consent form is not a valid option. The client is a minor and cannot legally consent to their own treatment without the permission of their guardian, unless they are emancipated, married, or pregnant.

Choice B reason: This is not the correct choice because asking the adult neighbor to sign the consent form is not a valid option. The adult neighbor is not a legal guardian or a close relative of the client and has no authority to consent to the client's treatment.

Choice C reason: This is not the correct choice because obtaining consent from the hospital administrator is not a valid option. The hospital administrator is not a medical professional or a legal representative of the client and has no authority to consent to the client's treatment.

Choice D reason: This is the correct choice because attempting to notify the client's guardian to obtain consent is the best option. The client's guardian is the person who has the legal right and responsibility to make decisions for the client's health care. The nurse should try to contact the guardian by phone or other means and obtain verbal or written consent for the emergency surgery. If the guardian cannot be reached, the nurse should follow the facility's policy and procedure for obtaining consent in emergency situations.

A. Suctioning a client's long-term tracheostomy B. Using a pain rating scale to monitor a client's pain level C. Performing a dressing change on a client's peripherally inserted central catheter D. Instructing a client on self-administration of a tap water enema

Correct Answer is B

Explanation

The correct answer is: B.

Choice A reason:

Suctioning a client's long-term tracheostomy is a complex procedure that involves sterile technique and assessment skills that are beyond the scope of assistive personnel's practice. It requires clinical judgment and the ability to respond to complications, which are responsibilities typically reserved for licensed nursing staff.

Choice B reason:

Using a pain rating scale to monitor a client's pain level is a task that can be delegated to assistive personnel. It involves asking the client to rate their pain on a scale, which does not require clinical judgment or advanced skills. The assistive personnel can then report the pain level to the nurse, who will make decisions regarding pain management.

Choice C reason:

Performing a dressing change on a client's peripherally inserted central catheter (PICC) is not within the scope of assistive personnel. This task requires aseptic technique and knowledge of PICC line management to prevent infection and other complications, which are typically the responsibility of the registered nurse or licensed practical nurse.

Choice D reason:

Instructing a client on self-administration of a tap water enema involves teaching and assessment to ensure the client understands and can perform the procedure safely. This is a task that requires licensed nursing knowledge and skills to educate the client and evaluate their competency.

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A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

Nursing Test Bank

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