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 i

HESI LPN

Leadership and Management HESI Quizlet

1. 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. Elevating the head of the client's bed to 30 degrees during mealtime
B. Withholding fluids until the end of the meal
C. Providing a 10-minute rest period prior to meals
D. Instructing the client to place her chin toward her chest when swallowing

Correct answer: D

Rationale: The correct technique for a client with dysphagia is to instruct them to place their chin toward their chest when swallowing. This action helps to close off the airway during swallowing, reducing the risk of aspiration. Elevating the head of the client's bed to 30 degrees during mealtime helps prevent aspiration, but this is not the responsibility of the AP. Withholding fluids until the end of the meal can lead to dehydration and is not a recommended practice. Providing a 10-minute rest period prior to meals is not specifically related to improving swallowing safety for clients with dysphagia.

2. Which of the following assessment tools is used to determine the patient's level of consciousness?

A. The Snellen Scale
B. The Norton Scale
C. The Morse Scale
D. The Glasgow Scale

Correct answer: D

Rationale: The correct answer is D, The Glasgow Scale. The Glasgow Coma Scale is specifically designed to assess a patient's level of consciousness by evaluating eye opening, verbal response, and motor response. Choices A, B, and C are incorrect because the Snellen Scale is used for vision testing, the Norton Scale is used for assessing the risk of pressure sores, and the Morse Scale is used for evaluating a patient's risk of falling, not for determining the level of consciousness.

3. A nurse in a long-term care facility is caring for a client who reports the AP repositioned him in bed using excessive force. Which of the following actions should the nurse take?

A. Document in the client's chart that an incident report has been filed.
B. Contact the nurse manager.
C. Reassure the client that the staff is well trained.
D. Call risk management to interview the client.

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to contact the nurse manager. By doing so, the nurse can escalate the issue appropriately, ensuring that the incident is addressed and necessary actions are taken. Documenting in the client's chart that an incident report has been filed (Choice A) may be necessary but should not be the first step. Reassuring the client that the staff is well trained (Choice C) does not address the client's concern and the need for intervention. Calling risk management to interview the client (Choice D) may be premature at this stage and should be handled by the nurse manager first.

4. What is the purpose of a healthcare audit?

A. To increase paperwork
B. To assess and improve quality of care
C. To reduce patient satisfaction
D. To limit healthcare services

Correct answer: B

Rationale: The correct answer is B: 'To assess and improve quality of care.' Healthcare audits are conducted to evaluate the quality and efficiency of healthcare services provided. Choice A, 'To increase paperwork,' is incorrect as audits aim to streamline processes and reduce unnecessary paperwork. Choice C, 'To reduce patient satisfaction,' is incorrect as audits are meant to identify areas for improvement to enhance patient satisfaction. Choice D, 'To limit healthcare services,' is also incorrect as audits help in optimizing healthcare services rather than limiting them.

5. Which anatomic malformations are associated with Tetralogy of Fallot?

A. A sub-aortic septal defect, an overriding aorta, left ventricular hypertrophy, and right ventricular outflow
B. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and left ventricular outflow
C. A sub-aortic septal defect, an overriding aorta, pulmonary atresia, and right ventricular outflow
D. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow

Correct answer: D

Rationale: Tetralogy of Fallot is characterized by a combination of four heart defects: a sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow obstruction. This leads to mixing of oxygen-poor and oxygen-rich blood, resulting in cyanosis. Therefore, the correct answer is D. Choices A, B, and C are incorrect because they do not accurately describe the specific combination of anatomic malformations seen in Tetralogy of Fallot.