HESI Registered Nurse EXIT Practice Exam

A nurse assists an 86-year-old with a clear liquid diet who begins to cough. What should the nurse do next?

1. Add a thickening agent to the fluids

2. Check the client's gag reflex

3. Feed only solid foods

4. Increase the rate of intravenous fluids

The correct answer is: Check the client's gag reflex

Once a nurse observes an 86-year-old patient on a clear liquid diet beginning to cough, it is crucial to assess the patient's swallowing ability, which is indicated by checking the gag reflex. The gag reflex is an important component of the swallowing process, and its presence or absence can help the nurse determine if the patient has the necessary protection of the airway and can handle liquids safely. If the gag reflex is diminished or absent, there may be a risk of aspiration, which can lead to serious complications such as pneumonia. By checking the gag reflex, the nurse can gather vital information to tailor the intervention appropriately, whether it’s providing alternative feeding methods or ensuring the patient receives assistance during meals. In contrast, adding a thickening agent may not address the immediate concern of coughing during swallowing, and feeding only solid foods would be inappropriate for someone who requires a clear liquid diet. Increasing the rate of intravenous fluids does not pertain directly to the issue of oral intake and swallowing safety at that moment. Therefore, the assessment of the gag reflex becomes an essential step in maintaining the patient's safety and ensuring proper care.