Examkin

Question

Difficulty: HardAccident, Error, and Injury Prevention

A practical nurse (PN) is providing care for an older adult client admitted with aspiration pneumonia secondary to severe dysphagia from a prior stroke. The client, who was previously resting quietly, suddenly becomes highly restless, agitated, and exhibits a weak, wet-sounding cough. Which action should the PN take first to prevent further injury?

  1. Immediately elevate the head of the bed to a high-Fowler's position and activate the bedside suction equipment.Answer
  2. B
    Direct the unlicensed assistive personnel (UAP) to carefully offer the client small sips of thickened liquids to clear the throat.
  3. C
    Document the sudden agitation as an expected behavioral manifestation of age-related dementia and attempt verbal reorientation.
  4. D
    Prioritize obtaining a comprehensive set of vital signs, including oxygen saturation, before altering the client's physical position.

Answer

The correct action is to immediately elevate the head of the bed to a high-Fowler's position and activate the bedside suction equipment.
The correct answer addresses the immediate threat to the client's life. Sudden restlessness and a wet-sounding cough in a client with severe dysphagia indicate acute aspiration and hypoxia. Elevating the head of the bed and utilizing suction are immediate, direct actions that prevent further aspiration and clear the airway, directly aligning with ABC prioritization and injury prevention standards.

Step-by-Step Solution

1
Assess the clinical scenario and the client's sudden change in condition.
The client is exhibiting sudden restlessness, agitation, and a wet cough, which are clinical indicators of acute airway compromise and active aspiration.
Recognizing signs of acute hypoxia and aspiration is critical for prioritizing care in vulnerable clients with severe dysphagia.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
Airway protection is the absolute highest priority to prevent further physical injury or respiratory arrest.
Physiological needs related to the airway always take precedence over obtaining vital signs, documenting, or delegating.
3
Determine the most appropriate immediate nursing intervention within the practical nurse (PN) scope of practice.
Elevating the head of the bed utilizes gravity to prevent further downward aspiration, and preparing suction equipment allows for immediate clearing of the airway.
These are direct, non-pharmacological safety measures that provide immediate airway protection before the registered nurse (RN) or provider arrives.

Key Concept

Airway Protection and Aspiration Prevention
Rate this question

Topics

Accident, Error, and Injury Prevention

More questions from this topic