The nurse cares for a client with a new order for aspiration precautions. What action(s) should the nurse incorporate into the client's plan of care? Select all that apply.

Keep suction equipment at the bedside.

Suggest the client use a straw to drink liquids.

Encourage slow, small bites.

Remain with the client during meals.

Monitor for coughing while eating.

Answer and Explanation

Correct Answer : A,C,D,E

Rationale:

A. Keeping suction equipment at the bedside is appropriate. Clients on aspiration precautions are at risk for inhaling food, liquids, or secretions into the airway. Having suction readily available ensures rapid intervention if choking or aspiration occurs, promoting airway safety.

B. Suggesting the client use a straw to drink liquids is not appropriate. Using a straw can increase the speed and volume of liquid entering the mouth, which may raise the risk of aspiration in clients with swallowing difficulties. Therefore, this action should not be included in the plan of care unless specifically ordered by a speech-language pathologist.

C. Encouraging slow, small bites is correct. Small bites reduce the risk of choking and allow the client more time to chew and swallow safely. This helps minimize the risk of aspiration and improves swallowing control.

D. Remaining with the client during meals is appropriate. Close supervision allows the nurse to monitor swallowing ability, ensure proper positioning, and intervene quickly if signs of aspiration occur.

E. Monitoring for coughing while eating is correct. Coughing, choking, throat clearing, or a wet voice during meals are signs of possible aspiration. Early recognition allows for prompt intervention and prevention of complications such as aspiration pneumonia.

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Correct Answer is C

Explanation

Rationale:
A. Placing the client’s first urine void in the collection container is incorrect because the first void of the day is always discarded in a 24-hour urine collection. The collection period begins with the second void, which is retained and then all subsequent urine is collected for the next 24 hours. Including the first void would result in inaccurate measurement of substances such as creatinine, protein, or electrolytes, which could affect diagnostic results.

B. Placing an external urinary catheter with a collection bag is outside the UAP’s scope of practice and is unnecessary for a routine 24-hour urine collection. Catheter insertion requires a licensed nurse to assess for complications and maintain sterile technique. Using a catheter when not indicated could increase the risk of infection and is not part of standard urine collection procedures.

C. Bringing a bucket of ice into the client’s bathroom shows that the UAP understands a critical aspect of 24-hour urine collection. Urine specimens must be kept cold during the collection period to prevent bacterial growth and chemical degradation, which ensures the accuracy and reliability of the laboratory results. This step is essential for maintaining specimen integrity over the entire 24-hour collection period.

D. Instructing the client to urinate directly into the specimen container for the first void is incorrect. The first void must be discarded, and the client’s urine for the remainder of the 24-hour period must be collected according to the protocol. Direct collection for the first void would compromise the accuracy of the test results.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

Rationale:

Chest tightness is correct for Blank 1 because this symptom may indicate a potentially life-threatening condition such as cardiac or respiratory compromise. Using the ABC priority framework, physiological stability and possible airway, breathing, or circulation issues must be addressed first.
Anxiety is correct for Blank 2 because once immediate physiological threats are assessed, psychological distress should be evaluated. Anxiety can contribute to physical symptoms and may worsen chest discomfort.
No appetite is correct for Blank 3 because while important, it is not an immediate threat to physiological stability. Appetite changes can be addressed after ruling out serious causes of chest tightness and evaluating anxiety.

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The nurse cares for a client with a new order for aspiration precautions. What action(s) should the nurse incorporate into the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse delegates a 24-hour urine specimen collection to the unlicensed assistive personnel (UAP). Which action shows the UAP understands the urine collection process?

Correct Answer is C

Explanation

Complete the following sentence by choosing from the list of option. A nurse is caring for a client who reports anxiety, chest tightness, and no appetite. The nurse should first assess the client's dropdown then their dropdown, and then their dropdown

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

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