A nurse is supervising 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?

Providing a 10min 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 B

a.   Providing a rest period prior to meals may be appropriate for some clients, but 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 helps prevent aspiration and facilitates swallowing in clients with dysphagia.
c.   Instructing the client to place her chin toward her chest when swallowing is not recommended and may increase the risk of aspiration.
d.   Withholding fluids until the end of the meal is not recommended for clients with dysphagia, as they may need fluids to help with swallowing and to prevent dehydration.

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Correct Answer is A

Explanation

a. In emergency situations where immediate treatment is necessary to stabilize the client and prevent further deterioration, obtaining written consent may not be feasible or necessary. The principle of implied consent applies in emergency situations where the client is unable to provide consent due to their condition.

b. Notifying risk management before initiating treatment is not necessary in this emergency situation, as the priority is to provide timely and appropriate care to the client.
c. Having the client sign a consent for treatment may not be possible if the client is disoriented or incapacitated due to their condition.

d. Contacting the client's next of kin to obtain consent may delay necessary treatment, which could be detrimental to the client's health in an emergency situation.

A. MS 10mg IV every 4 hrs. prn for pain B. Morphine sulfate 10mg IV q 4hrs. IV prn for pain C. MSO4 10mg IVP q 4hrs prn for pain D. Morphine sulfate 10.0mg every 4 hours IV prn for pain

Correct Answer is B

Explanation

Rationale for A: The abbreviation "MS" is not recommended for use in prescriptions because it can be confused with magnesium sulfate or morphine sulfate. This can lead to medication errors, making this option unsafe for transcription.

Rationale for B: This prescription is the correct choice because it clearly spells out "morphine sulfate," avoiding any potential confusion with similar abbreviations. It also uses the appropriate dosage and frequency without unnecessary trailing zeros, reducing the risk of errors.

Rationale for C: The abbreviation "MSO4" is considered dangerous because it can be confused with magnesium sulfate (MgSO4). Additionally, using abbreviations in prescriptions can lead to misinterpretation and medication errors.

Rationale for D: Although this option spells out "morphine sulfate," it uses a trailing zero in "10.0 mg," which can be misinterpreted as a higher dose, such as 100 mg. Trailing zeros should be avoided to prevent potential overdose.

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A nurse is supervising 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

Naxlex Comprehensive Predictor Exams

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