NCLEX-RN

Category - Care Management

It is lunchtime on Nina the New Nurse’s unit. Nina the New Nurse observes the nurse’s aide assisting a client with right-sided paralysis and dysphagia. The client is sitting in a chair, with his head positioned slightly forward. Nina the New Nurse watches as the aide mixes a little water into the pudding, carefully placing a small spoonful towards the back of the client’s mouth, on the left side. The nurse aide offers the client sips of milk occasionally. The NA is unhurried while assisting the client, taking her cues from the client. Nina the New Nurse is pleased with what she has observed. What, if anything, has Nina the New Nurse done wrong?
  1. Nina the New Nurse has not done anything wrong.
  2. Nina the New Nurse should have offered the nursing assistant praise and appreciation for a job well done.
  3. Nina the New Nurse should have intervened by instructing the nursing assistant on proper positioning of a client with dysphagia.
  4. Nina the New Nurse should have intervened for something not mentioned in any of the answer choices.
Explanation
Answer: D - Nina the New Nurse should have intervened by educating the NA on proper consistency of liquids for a client with dysphagia. When Nina the New Nurse observed the nursing assistant adding water to the pudding (thinning the consistency), she should have educated the nursing aide that thin liquids can present a choking hazard for a client with dysphagia. It is the nurse’s responsibility to ensure the healthcare team meets the client’s safety needs.
Was this helpful? Upvote!
Login to contribute your own answer or details

Top questions

Related questions

Most popular on PracticeQuiz