The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

The consistency of the prescribed diet.

Review of current medications.

Client's ability to chew and swallow.

The client's respiratory rate and lung sounds.

Answer and Explanation

The Correct Answer is C

A.   Knowing the consistency of the prescribed diet (e.g., pureed, mechanical soft, or regular) is important for planning the feeding process and ensuring that the diet meets the client's needs and restrictions. However, this information is secondary to assessing the client’s ability to safely chew and swallow.
B.   While reviewing current medications is important for understanding potential drug interactions, side effects, or dietary restrictions, it is not the most immediate concern before feeding. Medications can influence appetite and digestion, but the priority is ensuring the client can safely handle the food.
C.   This is the most critical information to obtain before feeding a debilitated client. Assessing the client's ability to chew and swallow helps prevent complications such as aspiration, choking, or aspiration pneumonia. The nurse should ensure that the client can safely manage the food given to them and that their swallowing mechanisms are functioning adequately.
D.   While monitoring the respiratory rate and lung sounds is important for overall health assessment, it is not the immediate priority before starting a feeding session. However, it is important to monitor for signs of aspiration during and after feeding, as compromised swallowing can lead to aspiration pneumonia.

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Correct Answer is B

Explanation

A. Document in the EHR: While documenting the event in the electronic health record is important, it's not sufficient to address the medication error. An incident report provides a more comprehensive and structured approach to documenting and investigating the event.
B. When a medication error occurs, it's crucial to document the event through an incident report. This helps to identify the root cause of the error, prevent similar occurrences in the future, and ensure patient safety. An incident report should include a detailed description of the event, the actions taken, and any potential contributing factors.
C. While informing the next shift is important for continuity of care, it's not the most immediate action needed to address the medication error. Completing an incident report is a higher priority.
D. Notifying the healthcare provider is important, but it should be done in conjunction with completing an incident report. The incident report provides a detailed record of the event, which can be shared with the healthcare provider for further review and investigation.

A. Use a belt restraint to secure the client in the chair. B. Empty the client's urinary drainage bag. C. Reposition the client's urinary drainage bag. D. Elevate the client's feet higher on the foot rests.

Correct Answer is C

Explanation

A. Using a belt restraint is generally not recommended unless specifically ordered for safety reasons, as it may not be appropriate or necessary in all cases. Restraints should only be used when absolutely needed and when all other methods of ensuring safety have been considered.
B. Emptying the urinary drainage bag before moving the client is important to prevent overflows and ensure that the bag does not become a source of discomfort or potential infection. However, this step might not always be immediately necessary unless the bag is full or the client’s comfort and hygiene are at risk.
C. Repositioning the urinary drainage bag is crucial for ensuring that the bag remains below the level of the bladder and is not subject to kinks or obstructions. This helps prevent backflow and potential infections. Proper positioning also contributes to the client’s comfort and dignity, making this a priority before moving the client.
D. Elevating the client’s feet on the footrests is important for their comfort and to prevent swelling or pressure sores, especially if the client has limited mobility or circulatory issues. Proper positioning can prevent discomfort and promote better circulation, which is essential for maintaining the client’s well- being during transport.

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The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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