Examkin

Question

Difficulty: MediumBasic Care and Comfort

A practical nurse (PN) is preparing to assist a client with their morning meal. The client is 48 hours postoperative following a carotid endarterectomy and has residual dysphagia from a previous cerebrovascular accident (CVA). The client is also reporting mild shoulder pain. Which action is the priority for the PN to ensure safe and comfortable care?

  1. A
    Elevate the head of the bed to 30 degrees so the client can rest comfortably after their surgery.
  2. B
    Administer a PRN oral analgesic with a cup of water to relieve the shoulder pain before serving the meal.
  3. Position the client upright at a 90-degree angle and instruct them to tuck their chin when swallowing.Answer
  4. D
    State to the client, 'Don't worry about your swallowing difficulty; you will be completely fine if you just take small bites.'

Answer

Positioning the client upright at a 90-degree angle and instructing them to tuck their chin when swallowing.
Clients with dysphagia are at a high risk for aspiration. Placing the client in a high-Fowler's position (90-degree angle) utilizes gravity to facilitate safe swallowing, while the chin-tuck maneuver anatomically narrows the airway opening. Together, these actions direct food and fluids safely into the esophagus and prevent aspiration.

Step-by-Step Solution

1
Identify the client's primary risk factor based on the provided medical history.
The client has residual dysphagia (difficulty swallowing) and is recovering from surgery.
Dysphagia places the client at a high risk for aspiration during any oral intake.
2
Determine the priority of care using the Airway, Breathing, Circulation (ABC) framework.
Protecting the airway from aspiration takes immediate precedence over secondary issues such as mild shoulder pain or surgical rest.
Aspiration can lead to severe airway obstruction or aspiration pneumonia, which are life-threatening complications.
3
Select the nursing intervention that best protects the airway while facilitating basic care and feeding.
Placing the client in a high-Fowler's position (90 degrees) and utilizing the chin-tuck maneuver.
This anatomical positioning utilizes gravity to direct food toward the esophagus while narrowing the airway opening, thereby minimizing the risk of aspiration.

Key Concept

Aspiration Precautions and Dysphagia Management
Rate this question

Topics

Basic Care and Comfort

More questions from this topic