NCLEX Practice Test

A nurse receives shift report and is told to prioritize the care of a client with a subdural hemorrhage who is requesting food. What is the most important consideration in this situation?

1. Assess the client's ability to swallow

2. Determine if the client is still on NPO status

3. Request a dietary consult for the client

4. Verify the order for the client's diet

The correct answer is: Assess the client's ability to swallow

The most important consideration in this situation is to assess the client's ability to swallow. A subdural hemorrhage can lead to neurological changes that may affect the client’s ability to swallow safely. Assessing this ability is crucial because if the client has dysphagia, eating could lead to aspiration pneumonia or choking. Ensuring that the client can safely ingest food is a fundamental nursing responsibility when a patient expresses hunger or a desire to eat, particularly after sustaining a head injury. While determining if the client is still on NPO status, requesting a dietary consult, and verifying diet orders are important steps in the care process, they become less relevant without first confirming the client's capacity to swallow. If the client is unable to swallow effectively, the other considerations may become moot as the priority is ensuring the client's immediate safety.