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 A

Explanation

A. Orange slices: Orange slices should be avoided because they contain a fibrous membrane that can be difficult to chew and swallow, posing a choking risk. Additionally, the acidic nature of oranges may cause irritation in some clients.

B. Ground hamburger: Appropriate for a mechanical soft diet because it is easy to chew and swallow.

C. Cooked green beans: Softened through cooking, making them easy to chew.

D. Canned peaches: Soft and easy to chew, making them suitable for this diet.

A. Report the finding to the provider. B. Compare the finding to the client's blood pressure baseline. C. Administer antihypertensive medications as prescribed. D. Recheck the client's blood pressure.

Correct Answer is D

Explanation

A. Report the finding to the provider. While the provider should be informed if the hypertension is new, persistent, or symptomatic, the nurse should first verify the blood pressure before escalating the concern.

B. Compare the finding to the client's blood pressure baseline. Checking the baseline is important, but the first action should be to confirm the accuracy of the reading by rechecking it. If the reading is consistent with previous values, the nurse can then compare it to the baseline.

C. Administer antihypertensive medications as prescribed. Administering medication without confirming the blood pressure reading could lead to unnecessary treatment or hypotension if the reading was inaccurate. The nurse should first recheck the BP.

D. Recheck the client's blood pressure. Rechecking the blood pressure ensures accuracy before making clinical decisions. Factors such as incorrect cuff size, client positioning, or transient increases (e.g., anxiety or pain) could cause an elevated reading. If the elevated BP is confirmed, then further action (e.g., notifying the provider or administering medication) can be taken.

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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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