A patient is at risk for aspiration. What nursing action is most appropriate?
a. Hold the patient's cup for him so he can concentrate on taking pills.
b. Thin out liquids so they are easier to swallow.
c. Give the patient a straw to control the flow of liquids.
d. Have the patient self-administer the medication.
D
Aspiration occurs when food, fluid, or medication intended for GI administration inadvertently enters the respiratory tract. To minimize aspiration risk, allow the patient, if capable, to self-administer medication. Patients should also hold their own cup to control how quickly they take in fluid. Liquids should be thickened to reduce the risk of aspiration. Patients at risk for aspiration should not be given straws because use of a straw decreases the control the patient has over volume intake.
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1. They require two or more nurses to implement. 2. They require that the nurse consult a pharmacist. 3. They require a written or verbal prescription. 4. They take longer than one shift to implement.
The nurse is observing a student provide care to a client who is in early labor. Which student actions should be corrected?
1. Applying a fetal heart monitor followed by an explanation of the reason for its use 2. Upon entering the room, speaking with the client prior to looking at the fetal heart monitor 3. Using layman's terms to provide the client with an explanation of the reason for electronic fetal monitoring 4. Incorporating cues that arise from intuition or from observations of the client and family as opposed to focusing on the fetal heart monitor
When inspecting a patient's eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally. What other technique does a nurse use to test the function of this cranial nerve?
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