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: This is the correct choice because autonomy is the ethical principle that respects the client's right to make their own decisions about their health care. The nurse should honor the client's wishes and preferences, even if they differ from the nurse's or the provider's. The nurse should not force or coerce the client to accept blood transfusions, as this would violate their autonomy.
Choice B reason: This is not the correct choice because fidelity is the ethical principle that requires the nurse to be faithful and loyal to the client and their agreement. The nurse should keep their promises and commitments, and act in the best interest of the client. The nurse should not administer blood transfusions to the client without their consent, as this would breach their trust and fidelity.
Choice C reason: This is not the correct choice because justice is the ethical principle that ensures fair and equal treatment for all clients. The nurse should distribute resources and services according to the client's needs and rights, and avoid any discrimination or bias. The nurse should not administer blood transfusions to the client against their will, as this would disregard their justice.
Choice D reason: This is not the correct choice because veracity is the ethical principle that obliges the nurse to be honest and truthful with the client. The nurse should provide accurate and complete information, and disclose any errors or risks. The nurse should not administer blood transfusions to the client without informing them, as this would violate their veracity.
Correct Answer is B
Explanation
Choice A reason: Information regarding organ donation is not part of advance directives, but rather a separate document that the client can sign to indicate their willingness to donate their organs or tissues after death. The nurse should inform the client about the option and process of organ donation, but not include it in the advance directives.
Choice B reason: Instructions regarding treatments the client desires or does not desire is part of advance directives, as it allows the client to express their preferences and values regarding their health care in case they become unable to make decisions for themselves. The nurse should help the client understand the benefits and risks of different treatments and document their choices in the advance directives.
Choice C reason: Information regarding the disposition of the client's body upon death is not part of advance directives, but rather a personal or legal matter that the client can arrange with their family or attorney. The nurse should respect the client's wishes regarding their body after death, but not include it in the advance directives.
Choice D reason: A form with directions for contacting next of kin is not part of advance directives, but rather a routine document that the client can fill out when they are admitted to the facility. The nurse should obtain the client's contact information and emergency contacts, but not include it in the advance directives.
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