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 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.

3. Which of the following is considered normal for the neonate?

A. Chest Circumference: 10 to 13 inches
B. Length: 16 to 22 inches
C. Weight: 1,500 to 4,000 g
D. Head Circumference: 12.6 to 14.5 inches

Correct answer: D

Rationale: A normal head circumference for a neonate typically falls within the range of 12.6 to 14.5 inches. Choice A is incorrect because the chest circumference for a neonate is usually smaller. Choice B is incorrect as the length of a neonate is typically shorter. Choice C is incorrect as the weight of a neonate is usually measured in grams and falls within a different range.

4. What is the significance of patient advocacy in nursing?

A. Prioritizing the needs of the healthcare team over the patient
B. Ensuring that patients' rights and preferences are respected
C. Limiting patient autonomy
D. Focusing solely on clinical procedures

Correct answer: B

Rationale: Patient advocacy in nursing entails ensuring that patients' rights and preferences are respected. This involves advocating for the patients' best interests, supporting informed decision-making, and safeguarding their autonomy. Choice A is incorrect because patient advocacy focuses on the patient's needs, not the healthcare team's. Choice C is incorrect as patient advocacy aims to empower patients and enhance their autonomy rather than limiting it. Choice D is incorrect since patient advocacy goes beyond clinical procedures to encompass holistic care that addresses the patients' preferences and rights.

5. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

A. Twitching
B. Positive Trousseau's sign
C. Hyperactive bowel sounds
D. Hyperactive deep tendon reflexes

Correct answer: A

Rationale: The correct answer is A: Twitching. Hypocalcemia often presents with neuromuscular irritability, leading to manifestations such as twitching. Trousseau's sign is actually a positive indicator of hypocalcemia, not negative, making choice B incorrect. Hypoactive bowel sounds are not typically associated with hypocalcemia, making choice C incorrect. Similarly, hypoactive deep tendon reflexes are not a common finding in hypocalcemia, making choice D incorrect.