A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse Include In the plan?

Ask the client to tilt their head back when swallowing.

Have the client sit upright for 1 hr following meals.

Administer liquids to the client using a syringe.

Allow the client to rest for 10 min prior to eating.

Answer and Explanation

The Correct Answer is B

A. Ask the client to tilt their head back when swallowing. Tilting the head back increases the risk of aspiration by opening the airway. Instead, the "chin tuck" method is recommended.

B. Have the client sit upright for 1 hr following meals. Sitting upright for an extended period reduces the risk of aspiration by allowing gravity to assist in digestion.

C. Administer liquids to the client using a syringe. Using a syringe can increase the risk of aspiration and does not allow the client to control swallowing.

D. Allow the client to rest for 10 min prior to eating. While rest may help conserve energy, it is not a priority intervention for dysphagia management.

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Correct Answer is C

Explanation

A. Remove a piece of the new dressing that falls 5 cm (2 in) from the edge of the sterile field during the dressing change. Incorrect, as the item is contaminated and should not be used.

B. Begin the dressing change by applying sterile gloves and removing the existing dressing. The old dressing should be removed with clean gloves before donning sterile gloves.

C. Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray. Any contamination of the sterile field requires a complete restart to maintain sterility.

D. Place the existing dressing on the outermost portion of the sterile field and discard it when the dressing change is finished. Contaminates the sterile field; old dressings should be disposed of immediately.

A. Presence of WBCs in urine B. Cloudy urine C. Urinary urgency D. Bladder distention

Correct Answer is D

Explanation

A. Presence of WBCs in urine : This suggests a possible infection, not necessarily a blockage.

B. Cloudy urine : This may indicate an infection but is not specific for occlusion.

C. Urinary urgency: A client with a catheter should not experience urgency since urine continuously drains.

D. Bladder distention: If the catheter is occluded, urine will accumulate in the bladder, leading to distention.

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A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse Include In the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is D

Explanation

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A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse Include In the plan?