Question

A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Alternate the client's liquids and solids during meals.

Rationale :

💎Clients with dysphagia are at risk for aspiration due to impaired swallowing.

💎Alternating solids and liquids helps clear the throat and esophagus, reducing food sticking and lowering aspiration risk.

💎The head should be elevated to at least 90°, not just 45°, during meals for maximum airway protection.

💎Tilting the head back actually increases the chance of aspiration, as it opens the airway rather than protecting it.

💎Minimizing distractions (e.g., turning off the TV) also improves focus, but the priority safety action is alternating food textures.

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Answer 2

Correct Answers:

Position the client supine.

Rationale :

🛡Removing a catheter begins with placing the client in a supine position, which allows for relaxation of the pelvic muscles and safe removal.

🛡After positioning, the balloon should be fully deflated before removal to prevent urethral trauma.

🛡The client does not need to bear down during removal, as this can cause discomfort and resistance.

🛡Cleaning the perineum is important for hygiene, but it is performed after catheter removal, not as the first action.

🛡Correct positioning is the priority step that ensures safe and effective removal.

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Answer 3

Correct Answers:

Add thickener to fluids.

Rationale :

🍵Thickened liquids move more slowly, giving clients with dysphagia greater control during swallowing.

🍵This reduces the risk of aspiration and choking, particularly in clients post-stroke with neuromuscular weakness.

🍵Placing food on the affected (left) side may worsen aspiration risk due to impaired chewing and swallowing.

🍵Tilting the head back is unsafe because it increases the risk of fluid entering the airway.

🍵Thickening agents are a proven evidence-based intervention for swallow safety.

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Answer 4

Correct Answers:

Explain to the client that she will feel temporary discomfort.

Rationale :

🩺Before any invasive procedure, the nurse must provide client education and explanation to promote cooperation and reduce anxiety. 🩺This step follows the nursing process principle of “explain before you do.” 🩺Lubricating the catheter, preparing sterile supplies, and cleaning the perineum are technical steps that follow afterward. 🩺Explaining first ensures the client understands what to expect and gives informed consent for care. 🩺Proper communication also strengthens nurse–client trust.

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Answer 5

Correct Answers:

Urinary tract infection

Rationale :

🧪Dark amber, cloudy urine with a foul odor is a classic sign of UTI due to bacterial presence and pyuria.

🧪The odor results from ammonia or bacterial metabolites, and cloudiness indicates white blood cells and debris.

🧪Retention causes incomplete emptying but usually not odor and cloudiness unless infection develops.

🧪Incontinence and frequency are symptoms but do not explain the urine characteristics described.

🧪The nurse should anticipate provider orders for urinalysis and culture to confirm UTI.

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Answer 6

Correct Answers:

Leakage of urine

Rationale :

🔵Clients with urinary retention may experience overflow incontinence, where the bladder becomes overly full and small amounts of urine leak involuntarily.

🔵This occurs because the bladder cannot fully empty, leading to increased bladder pressure that forces urine to escape through the urethra.

🔵Dark-colored, bloody, or cloudy urine are not typical of retention, but leakage directly correlates with distended bladder overflow.

🔵Nurses should assess for bladder distention and perform a bladder scan to confirm retention.

🔵Early recognition is important to prevent complications such as urinary tract infections and renal damage.

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Answer 7

Correct Answers:

Stay with the client during meals and for 1 hr afterward.
Offer specific privileges for sustained weight gain.
Monitor the client's weight daily after first voiding.

Rationale :

Stay with the client during meals and for 1 hr afterward

🔷Continuous presence during and after meals reduces opportunities for compensatory behaviors (e.g., vomiting, exercising, food disposal), directly supporting nutritional restoration.

🔷The 1-hour post-meal observation window targets the period of highest risk for purging, which is critical to prevent relapse-reinforcing behaviors.

🔷Consistent monitoring provides behavioral containment, lowering anxiety around eating while reinforcing meal completion as a therapeutic target.

🔷This approach aligns with structured eating-disorder protocols that pair supervised meals with post-meal support to improve medical stability.

🔷Nurse presence also enables real-time coaching on coping skills (paced breathing, grounding), strengthening therapeutic alliance and adherence.

Offer specific privileges for sustained weight gain

🔷Using positive reinforcement (e.g., phone time, supervised passes) for sustained weight gain operationalizes treatment goals into observable, rewarded behaviors.

🔷Clearly defined, objective criteria (e.g., steady, clinically safe weight gain) enhance patient accountability and reduce ambiguity that can fuel resistance.

🔷Privilege systems are a core element of behavioral modification, helping transition motivation from external prompts to internalized recovery goals.

🔷This strategy complements psychotherapy and nutrition plans by linking functional rewards to health-restoring behaviors, not to food itself.

🔷Documented progress tied to privileges provides transparent feedback, which supports treatment engagement and reduces power struggles.

Monitor the client's weight daily after first voiding

🔷Daily morning weights after first void standardize conditions (empty bladder, pre-breakfast), yielding accurate trend data for medical decision-making.

🔷Standardization limits artifacts from fluid shifts, clothing differences, and intake, enabling early detection of edema, dehydration, or manipulation.

🔷Pairing weights with the same scale and gown enhances reliability, which is essential for adjusting caloric prescriptions and activity levels.

🔷In many programs, blind weights (not sharing the number) help reduce weight-focused anxiety while still informing the clinical team.

🔷Accurate trending is foundational to preventing re-feeding complications, guiding electrolyte monitoring, and ensuring safe, gradual restoration.

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Answer 8

Correct Answers:

Gelatin

Rationale :

🟡A clear liquid diet includes foods that are liquid at room temperature and leave little to no residue in the GI tract.

🟡Gelatin is appropriate because it is transparent, easy to digest, and does not increase stool bulk.

🟡This type of diet is often prescribed postoperatively or during acute GI illness to maintain hydration and rest the bowel.

🟡Pureed foods, yogurt, and strained soups are not considered clear because they contain protein, fat, or fiber.

🟡Teaching caregivers about appropriate clear liquids helps ensure safe recovery and prevention of complications.

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Answer 9

Correct Answers:

Lubricate the catheter 2.5 to 5 cm (1 to 2 in)

Rationale :

🔴Adequate lubrication of the catheter tip reduces friction and discomfort during insertion in female clients.

🔴The recommended amount for adult females is 2.5–5 cm (1–2 inches) to protect delicate mucosal tissue.

🔴Proper lubrication also reduces the risk of urethral trauma and infection.

🔴Other aspects of catheterization require strict sterile technique, but lubrication length is key for safe passage.

🔴This step is essential in promoting client comfort and ensuring successful placement of the catheter.

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Answer 10

Correct Answers:

Abdominal distention

Rationale :

⚫Total parenteral nutrition (TPN) bypasses the GI tract and provides nutrients intravenously, but it carries risks of metabolic and gastrointestinal complications.

⚫Abdominal distention can result from fluid and electrolyte imbalances associated with TPN therapy.

⚫This may indicate delayed gastric emptying, intolerance, or complications like infection or liver dysfunction.

⚫Nurses must closely monitor for signs of distention as it may compromise comfort and respiratory function.

⚫Ongoing assessment helps identify early complications and ensures safe continuation of therapy.

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QLexNursing

1 :
A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?

2 :
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

3 :
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?

4 :
A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first?

5 :
A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

6 :
A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?

7 :
A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)

8 :
A nurse is reinforcing instructions with the parent of a toddler about foods that are included on a clear liquid diet. Which of the following foods suggested by the parent indicates understanding of the instructions?

9 :
A nurse is planning to insert an indwelling urinary catheter for an adult female client. Which of the following actions should the nurse plan to take?

10 :
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which of the following conditions as a complication TΡΝ?

QLexNursing

1 : A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?

2 : A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

3 : A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?

4 : A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first?

5 : A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

6 : A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?

7 : A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)

8 : A nurse is reinforcing instructions with the parent of a toddler about foods that are included on a clear liquid diet. Which of the following foods suggested by the parent indicates understanding of the instructions?

9 : A nurse is planning to insert an indwelling urinary catheter for an adult female client. Which of the following actions should the nurse plan to take?

10 : A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which of the following conditions as a complication TΡΝ?

1 :
A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?

2 :
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

3 :
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?

4 :
A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first?

5 :
A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

6 :
A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?

7 :
A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)

8 :
A nurse is reinforcing instructions with the parent of a toddler about foods that are included on a clear liquid diet. Which of the following foods suggested by the parent indicates understanding of the instructions?

9 :
A nurse is planning to insert an indwelling urinary catheter for an adult female client. Which of the following actions should the nurse plan to take?

10 :
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which of the following conditions as a complication TΡΝ?