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Difficulty: HardBasic Care and Comfort

A practical nurse is assisting an older adult client with right-sided hemiplegia and known dysphagia with their afternoon meal. During the feeding, the client's voice suddenly becomes gurgly, and they begin to exhibit a weak, ineffective cough. Which action should the nurse implement first?

  1. Stop the feeding immediately, ensure the client remains in a high Fowler's position, and clear the oral cavity.Answer
  2. B
    Offer the client a small sip of clear water to help swallow the remaining food and clear the throat.
  3. C
    Lower the head of the bed slightly and assist the client to roll onto their affected right side to facilitate drainage.
  4. D
    Reassure the client that coughing is a normal part of relearning to swallow and advise them to eat more slowly.

Answer

The priority action is to immediately stop the feeding, maintain the client in a high Fowler's position, and clear the oral cavity to protect the airway.
A gurgly voice and a weak, ineffective cough in a client with dysphagia are cardinal signs of active aspiration. The absolute first priority is to protect the airway. This is accomplished by immediately stopping the feeding, maintaining the client in a fully upright (high Fowler's) position to prevent further downward transit of food, and clearing any residual food from the oral cavity.

Step-by-Step Solution

1
Recognize the clinical signs of active aspiration.
The nurse identifies that a gurgly, wet-sounding voice combined with a weak, ineffective cough means food or liquid has entered the trachea.
Rapid recognition of airway compromise is the first step in the nursing process (assessment/data collection) before taking action.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The nurse immediately halts the meal to prevent any further material from entering the mouth or airway.
Stopping the source of the aspiration is the most critical immediate intervention to protect the airway.
3
Implement appropriate positioning and clearance techniques.
The nurse keeps the client upright (high Fowler's) and clears any residual food from the mouth.
An upright position uses gravity to keep stomach contents down, and clearing the mouth prevents further aspiration of residual food.

Key Concept

Aspiration Precautions and Airway Prioritization during Basic Care
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Topics

Basic Care and Comfort

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