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Difficulty: HardBasic Care and Comfort

An older adult client is resting in bed after undergoing an endoscopic swallowing evaluation earlier in the shift. The nursing care plan notes that the client is experiencing intermittent confusion and requires assistance with oral intake and comfort measures. Which actions should the practical nurse select to safely implement basic care? Select all that apply.

  1. Verify the client's ability to swallow safely prior to initiating the prescribed clear liquid diet.Answer
  2. B
    Position the client flat in a supine position to promote rest and recovery from the endoscopy.
  3. C
    Explain to the family that intermittent confusion is a normal physiological response to aging.
  4. Provide warm saline gargles or throat lozenges to soothe localized oropharyngeal irritation.Answer
  5. E
    Apply soft limb restraints to prevent the disoriented client from dislodging the intravenous access device.
  6. Utilize a soft-bristled toothbrush or moistened sponge swab to perform comprehensive oral hygiene.Answer

Answer

The correct actions include verifying the client's ability to swallow safely before offering fluids, providing warm saline gargles or lozenges for throat discomfort, and using gentle tools for oral hygiene.
The correct actions prioritize airway safety and patient comfort. Verifying the ability to swallow safely prevents aspiration when resuming oral intake after an endoscopy. Providing warm saline gargles or lozenges addresses the expected localized throat irritation caused by the endoscopic tube, promoting comfort. Utilizing a soft-bristled brush or moistened swab ensures oral hygiene is maintained while preventing mucosal trauma in a potentially irritated oropharynx.

Step-by-Step Solution

1
Analyze the client's current physiological status and risks associated with a recent endoscopic procedure.
Identified high risk for aspiration and localized throat irritation.
Understanding procedural impacts helps prioritize airway safety and basic comfort.
2
Evaluate the significance of the client's intermittent confusion.
Determined that acute confusion is abnormal and requires further assessment, rather than being dismissed or immediately managed with restraints.
Recognizing delirium or hypoxia prevents inappropriate interventions and delays in care.
3
Select interventions that safely promote comfort and basic hygiene.
Chose gentle oral care, safe feeding practices, and non-pharmacological soothing measures.
These actions strictly align with the practical nurse's scope of practice for basic care and comfort.

Key Concept

Basic Care and Comfort: Post-Procedural Safety and Hygiene
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Topics

Basic Care and Comfort

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