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

Providing a 10 min rest period prior to meals

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

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

Withholding fluids until the end of the meal

Answer and Explanation

The Correct Answer is C

a. Providing a 10-minute rest period prior to meals:

This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.

b. Elevating the head of the client’s bed to 30 degrees during mealtime:

The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.

c. Instructing the client to place her chin toward her chest when swallowing:

This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.

d. Withholding fluids until the end of the meal:

Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.

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Correct Answer is D

Explanation

a. Involve the client’s partner to assist with the teaching session: While involving the client's partner can be helpful, it may not ensure effective communication if the partner also does not speak the same language as the client.

b. Incorporate gestures and hand signals when presenting information: This is an effective strategy to enhance communication with a client who speaks a different language. Non-verbal cues such as gestures and hand signals can help convey meaning and facilitate understanding.

c. Validate understanding by interpreting the client’s body language: Interpreting the client's body language can be helpful in assessing their level of understanding and engagement. However, it may not be sufficient for effective communication, especially if the client has questions or needs clarification.

d. Provide an interpreter when obtaining consent from the client: This is the most appropriate intervention. Using a professional interpreter ensures accurate communication between the nurse and the client, facilitating understanding and ensuring that the client's rights are upheld during the consent process.

A. The AP wears a surgical mask when caring for a client who has respiratory tuberculosis B. The AP uses alcohol-based hand sanitizer after emptying the bed pan on a client who has Clostridum-difficle C. The AP bundles the client side of linen inward when changing the sheets for a client who has an infected surgical wound D. The AP removes her gloves before leaving the room of a client who has MRSA

Correct Answer is ["C"]

Explanation

a. The AP wears a surgical mask when caring for a client who has respiratory tuberculosis.

Incorrect. AP should wear an N95 Maskwhen caring for a client with respiratory tuberculosis helps prevent the spread of airborne pathogens, protecting both the healthcare worker and others in the environment.

b. The AP uses alcohol-based hand sanitizer after emptying the bedpan of a client who has Clostridium difficile.

This action is incorrect. Alcohol-based hand sanitizers are not effective against the spores of Clostridium difficile. Handwashing with soap and water is necessary to effectively remove the spores.

c. The AP bundles the client side of linen inward when changing the sheets for a client who has an infected surgical wound.

When handling soiled linen, it is essential to fold the client side of the linen inward to minimize the spread of contaminants. This helps to ensure that any contaminated surfaces do not come into contact with other surfaces, which is crucial for preventing the spread of infection.

d. The AP removes her gloves before leaving the room of a client who has MRSA.

For MRSA (Methicillin-resistant Staphylococcus aureus), the AP should remove gloves and perform hand hygiene before leaving the room.

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A nurse is supervising an assistive personnel 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

Naxlex Comprehensive Predictor Exams

A nurse is preparing a teaching session with a client who speaks a different language than the nurse. Which of the following interventions should the nurse plan to include?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is evaluating an assistive personnel’s use of infection control precautions. Which of the following actions by the AP indicates correct use of the precautions?

Correct Answer is ["C"]

Explanation

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