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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Measuring the client's vital signs is the first action that the nurse should perform, as it helps to assess the client's condition and the possible effects of the medication error. The nurse should monitor the client's blood pressure, heart rate, and respiratory rate closely and report any changes or abnormalities to the provider.
Choice B reason: Completing an incident report is not the first action that the nurse should perform, as it does not address the client's immediate needs or safety. The nurse should complete an incident report after providing care to the client and documenting the medication error in the client's record. The incident report should include the facts of the error, the actions taken, and the outcome of the client.
Choice C reason: Informing the nurse manager is not the first action that the nurse should perform, as it does not provide any intervention or treatment for the client. The nurse should inform the nurse manager after measuring the client's vital signs and calling the provider. The nurse manager can offer support and guidance to the nurse and help with the follow-up actions.
Choice D reason: Calling the provider is not the first action that the nurse should perform, as it does not give the nurse any information about the client's status or the severity of the error. The nurse should call the provider after measuring the client's vital signs and reporting the findings. The provider can order any necessary tests or treatments for the client.
Correct Answer is B
Explanation
Choice A reason: Allowing the AP to document the vital signs prior to logging out is not a correct action, as it violates the principles of confidentiality and accountability. The nurse should not share their login credentials or allow anyone else to use their electronic record.
Choice B reason: Logging out so the AP can log in to document the vital signs is the correct action, as it ensures that the documentation is accurate, timely, and secure. The nurse should log out of the electronic record after completing their charting and allow the AP to log in using their own credentials.
Choice C reason: Offering to chart the vital signs for the AP is not a correct action, as it delays the documentation and increases the risk of errors. The nurse should not chart the vital signs for the AP, as they are not the ones who obtained them.
Choice D reason: Recommending the AP come back later when the record is available is not a correct action, as it also delays the documentation and reduces the availability of the electronic record. The nurse should not make the AP wait for the record, as it may affect the continuity of care.
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