QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS)
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A nurse is assisting a client with his meal that is at risk for
aspiration due to a stroke. What interventions should the nurse
take to prevent aspiration? Select all that apply.
Position the client in Fowler's position.
Instruct the client to tuck his chin when swallowing.
Provide oral hygiene before meals.
Position the client in Trendelenburg position.
Support client's upper back, neck and head during feeding. -
ANSWER-Position the client in Fowler's position.
Instruct the client to tuck his chin when swallowing.
Support client's upper back, neck and head during feeding.
To decrease the risk of aspiration for a stroke client, ensure the
clients position is upright, that the upper back and head are
supported during meals. Remind the client to tuck their chin
while swallowing, to guide the food's path. Avoid lowering the
head of bed during feedings. Oral care can improve the client's
well-being and increase the interest for eating, but does not
help prevent the potential for aspiration.
,A nurse is planning to discharge a client who had a stroke 1
week ago to home. The nurse should collaborate with which of
the following members of the interprofessional team to assist
the client with the preparation of nutritious meals?
Occupational therapist
Registered dietitian
Social worker
Case manager - ANSWER-Registered dietitian;
The nurse should collaborate with the registered dietitian for
assistance with the preparation of nutritious meals. The
registered dietitian has the specific dietary knowledge to assist
both the client and those who may be assisting the client.
A nurse is creating a plan of care for a client who is at risk for
falls. Which of the following interventions should the nurse
include in the plan?
Adjust the bed height to the level of the client's preference.
Place the client's personal items on the nightstand near the
head of the bed.
Have the client demonstrate the use of the call light.
,Encourage the client to wear socks at all times. - ANSWER-
Have the client demonstrate the use of the call light;
The nurse should teach the client how to use the call light to
receive assistance when there is a need to get out of bed or a
chair. The nurse should keep the call light within the client's
reach at all times and have the client demonstrate the ability to
use it properly.
A nurse is assisting a client to ambulate to the bathroom when
the client begins to fall. Which of the following actions should
the nurse take?
Place one foot in front of the other while spreading the feet
apart.
Lower the client to the floor by holding tightly to their gown.
Grasp the client around the chest until a second staff member
arrives with a chair.
Bend one knee and have the client lean into the nurse's
opposite leg. - ANSWER-Place one foot in front of the other
while spreading the feet apart;
The nurse should place one foot in front of the other while
spreading the feet farther apart to widen their own base of
support. Then the nurse should lower the client to the floor as
, smoothly as possible. This will assist with supporting the
client's weight and help to prevent injury to the nurse.
A nurse enters a client's room and finds the client on the floor
experiencing a seizure. Which of the following actions should
the nurse take?
Apply restraints to the client's arms and legs.
Transfer the client from the floor to the bed.
Insert a tongue depressor into the client's mouth.
Position the client on their side. - ANSWER-Position the client
on their side;
The nurse should position the client on their side. This assists
the client's airway to remain open and can prevent aspiration if
the client has emesis or secretions in their mouth.
A nurse is preparing to administer medications to a client.
Which of the following information should the nurse use to
verify the client's identity?
Home telephone number
The provider's name
Work address
Room number - ANSWER-Home telephone number;