Which of the following items on the tray should the nurse remove?

Vanilla pudding.

Cranberry juice.

Beef broth.

Orange gelatin.

Answer and Explanation

Correct Answer : A,D

Choice A rationale

Vanilla pudding is often restricted in dysphagia diets due to its smooth, slippery texture, which can be difficult to control in the oral cavity and increases the risk of aspiration into the airway. Individuals with dysphagia may have impaired swallowing mechanisms, making thin, liquid-like consistencies particularly hazardous.

Choice B rationale

Cranberry juice is a thin liquid and poses a significant aspiration risk for a patient with dysphagia. Thin liquids are difficult to manage in the mouth and throat, increasing the likelihood of the liquid entering the trachea instead of the esophagus. Patients with swallowing difficulties often require thickened liquids to improve bolus control.

Choice C rationale

Beef broth is a clear liquid and, similar to cranberry juice, presents a high risk of aspiration for a patient with dysphagia. Its thin consistency makes it challenging for individuals with impaired swallowing to control its movement, potentially leading to it entering the airway and causing respiratory complications.

Choice D rationale

Orange gelatin, while seemingly semi-solid, often melts into a thin liquid in the mouth due to body temperature. This change in consistency makes it difficult to control and increases the risk of aspiration in patients with dysphagia. Gelatin's slippery texture further compounds this risk.

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Correct Answer is D

Explanation

Choice A rationale

NPO (nothing by mouth) might be a temporary measure immediately following a stroke if aspiration risk is very high. However, prolonged NPO can lead to malnutrition and dehydration, hindering recovery. Nutritional support is crucial for stroke patients, so alternative feeding methods should be explored.

Choice B rationale

Total parenteral nutrition (TPN) is a method of providing nutrients intravenously, bypassing the gastrointestinal tract. It is usually reserved for patients with severe gastrointestinal dysfunction or when enteral feeding is not feasible or tolerated. While it provides nutrition, it carries risks of infection and metabolic complications and is not the first-line treatment for dysphagia.

Choice C rationale

A mechanical soft diet consists of foods that are easy to chew and swallow, reducing the risk of choking and aspiration in patients with mild to moderate dysphagia. This diet provides necessary nutrients while minimizing the effort required for safe oral intake, promoting better nutrition and hydration compared to NPO.

Choice D rationale

Supplements via NG tube provide enteral nutrition directly into the stomach or small intestine, bypassing the oral cavity and pharynx. This is an appropriate nutritional therapy for patients with severe dysphagia who cannot safely swallow even modified textures, ensuring adequate caloric and nutrient intake to support recovery and prevent malnutrition.

A. Call the MD. B. Give the patient a high-protein snack. C. Hang a bag of 10% dextrose solution (D10W). D. Flush the line when complete and wait for the pharmacy to supply the next bag.

Correct Answer is C

Explanation

Choice A rationale

While it is important to inform the physician about the delay in the TPN solution, the immediate priority is to maintain the patency of the central venous catheter and prevent hypoglycemia. Calling the MD should occur after taking steps to address the immediate risk.

Choice B rationale

Giving the patient a high-protein snack will not address the immediate issue of the TPN running out and the risk of hypoglycemia associated with the abrupt cessation of a high-glucose solution. TPN provides a significant amount of glucose, and suddenly stopping it can lead to a drop in blood sugar.

Choice C rationale

Hanging a bag of 10% dextrose solution (D10W) is the most appropriate immediate action. This will provide a continuous source of glucose to prevent hypoglycemia while waiting for the new TPN bag from the pharmacy. D10W is often used as a bridge solution in this situation. Normal blood glucose levels are typically 70-110 mg/dL.

Choice D rationale

Flushing the line and waiting for the pharmacy to supply the next bag without infusing any solution puts the patient at significant risk for hypoglycemia and can also lead to catheter occlusion. Maintaining a continuous infusion, even of D10W, is crucial. .

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Which of the following items on the tray should the nurse remove?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care of a client who has had a stroke and is experiencing severe dysphagia with choking and coughing while eating. Which of the following nutritional therapies should the nurse expect to include in the plan of care?

Correct Answer is D

Explanation

A client is receiving total parenteral nutrition (TPN). The nurse enters the room and discovers that the container only has 15 minutes of solution left.She calls the pharmacy and is told that the next bag will not be available for another hour.What must the nurse do next?

Correct Answer is C

Explanation

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