Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia.Which of the following actions by the AP should the nurse identify as correct technique?
A. Providing a 10 min rest period prior to meals
Providing a rest period prior to meals might be beneficial for some individuals but isn't directly related to correct feeding technique for someone with dysphagia.
B. Elevating the head of the client's bed to 30° during mealtime
Elevating the head of the client's bed to 30° during mealtime helps prevent aspiration and promotes safer swallowing for someone with dysphagia.
C. Withholding fluids until the end of the meal
Withholding fluids until the end of the meal is not appropriate as it can increase the risk of aspiration and dehydration.
D. Instructing the client to place her chin toward her chest when swallowing
Instructing the client to place her chin toward her chest when swallowing is not a recommended technique for someone with dysphagia as it can increase the risk of
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Leadership 2019 Proctored Exam. Take the full exam now
Full Explanation
A: Providing a 10-minute rest period prior to meals can be beneficial for some clients, but it is not specifically related to the prevention of aspiration in clients with dysphagia. Rest periods do not directly facilitate safer swallowing processes.
B: Elevating the head of the client's bed to 30° during mealtime is the correct technique for a client with dysphagia. This position helps prevent aspiration, which can occur if food or liquids enter the lungs instead of going down the esophagus. The semi-upright position aids in the proper alignment of the esophagus and reduces the risk of choking.
C: Withholding fluids until the end of the meal is not an appropriate technique for a client with dysphagia. Fluids are often needed to help swallow and clear the mouth of food particles. Additionally, providing fluids throughout the meal can help prevent dehydration.
D: Instructing the client to place her chin toward her chest when swallowing can help prevent aspiration in clients with dysphagia. However, this technique should be used in conjunction with other methods, such as the correct positioning of the bed, to ensure safety and effectiveness.
Similar Questions
A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?
A. A client who has an open fracture of the femur
A client with an open fracture of the femur requires immediate attention due to the risk of severe bleeding, infection, and potential damage to surrounding structures.
B. A client who has periorbital ecchymosis
Periorbital ecchymosis (bruising around the eyes) might indicate facial trauma but may not immediately threaten life or limb.
C. A client who has a deep partial thickness burn on the lower extremities
A deep partial thickness burn on the lower extremities is serious but might not be immediately life-threatening.
D. A client who has an asymmetrical thorax
An asymmetrical thorax could indicate various injuries, but the severity and immediate threat to life can vary widely based on the underlying cause.
Full Explanation
Rationale for A: An open fracture of the femur is serious and requires prompt treatment, but it does not typically indicate an immediate life threat compared to other conditions.
Rationale for B: Periorbital ecchymosis can indicate facial trauma, but it is not necessarily life-threatening and would not be prioritized as emergent.
Rationale for C: A deep partial thickness burn on the lower extremities is significant and requires treatment, but unless the burn covers a large area or is complicated by other factors, it is not the most critical issue compared to respiratory or cardiovascular threats.
Rationale for D: An asymmetrical thorax may suggest a possible pneumothorax or other significant respiratory issue, which could lead to respiratory distress or failure. This client should be tagged as emergent due to the potential for rapid deterioration.
A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of the interdisciplinary team should the nurse contact for assistance?
A. Physical therapist
A physical therapist can assist with the proper application and usage of transcutaneous electrical nerve stimulation (TENS) for pain management, providing guidance on its use and techniques for optimal outcomes.
B. Occupational therapist
Occupational therapists focus more on functional activities related to daily living.
C. Respiratory therapist
Respiratory therapists specialize in respiratory care.
D. Pharmacist
Pharmacists primarily handle medication-related concerns and may not specifically assist with TENS therapy.
Full Explanation
A. A physical therapist can assist with the proper application and usage of transcutaneous electrical nerve stimulation (TENS) for pain management, providing guidance on its use and techniques for optimal outcomes.
B. Occupational therapists focus more on functional activities related to daily living.
C. Respiratory therapists specialize in respiratory care.
D. Pharmacists primarily handle medication-related concerns and may not specifically assist with TENS therapy.
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference?
A. A client who is at 39 weeks of gestation and has a negative contraction stress test
A client at 39 weeks of gestation with a negative contraction stress test is at term and might not require an interdisciplinary care conference if the test results are normal.
B. A client who is at 35 weeks of gestation and has a biophysical profile of 6
A client at 35 weeks of gestation with a biophysical profile of 6 might need further evaluation or interventions, making it appropriate to discuss the case in aninterdisciplinary care conference.
C. A client who is at 37 weeks of gestation and has an US ratio of 2:1
A client at 37 weeks of gestation with a specific US ratio might require attention, but the significance of the ratio in this context is unclear without additional information.
D. A client who is at 28 weeks of gestation and has a negative Coombs' titer
A client at 28 weeks of gestation with a negative Coombs' titer might not require an interdisciplinary care conference solely based on this information.
Full Explanation
A. A client at 39 weeks of gestation with a negative contraction stress test is at term and might not require an interdisciplinary care conference if the test results are normal.
B. A client at 35 weeks of gestation with a biophysical profile of 6 might need further evaluation or interventions, making it appropriate to discuss the case in an
interdisciplinary care conference.
C. A client at 37 weeks of gestation with a specific US ratio might require attention, but the significance of the ratio in this context is unclear without additional information.
D. A client at 28 weeks of gestation with a negative Coombs' titer might not require an interdisciplinary care conference solely based on this information.