The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?
Delegate the feeding to the nursing student.
Place the food on the affected side of the mouth.
Keep the television off while feeding the client.
Ensure the client's head of the bed is less than 30 degrees.
The Correct Answer is C
A. While the nursing student may assist with feeding, the nurse should always assess the client's swallowing ability and provide direct supervision to ensure the client's safety.
B. Placing food on the affected side of the mouth can increase the risk of aspiration. The food should be placed on the unaffected side of the mouth.
C. Distractions can impair the client's ability to focus on swallowing and increase the risk of aspiration. A quiet environment can help the client concentrate on eating.
D. The head of the bed should be elevated to at least 30 degrees during and after feeding to reduce the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["14"]
Explanation
154 lbs ÷ 2.2 lbs/kg = 70 kg
20 units/kg * 70 kg = 1400 units
1400 units ÷ 25,000 units/250 mL = 14 mL
Therefore, the nurse will administer 14 mL of Heparin.
Correct Answer is A
Explanation
A. The elevated pH and decreased PaCO2 indicate that the respiratory system is causing alkalosis, typically due to hyperventilation (excessive breathing).
B. Metabolic alkalosis would be indicated by a high pH with a normal or high HCO3. Since the HCO3 level is normal and the PaCO2 is low, this does not fit the picture of metabolic alkalosis.
C. Respiratory acidosis would be characterized by a low pH and an elevated PaCO2 due to inadequate ventilation and accumulation of carbon dioxide. Here, the pH is high, and the PaCO2 is low.
D. Metabolic acidosis would be indicated by a low pH with a low HCO3. In this case, the pH is high, and the HCO3 is normal.
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