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Difficulty: EasyBasic Care and Comfort

A practical nurse is providing basic care for a client who is 24 hours post-operative and experiencing temporary dysphagia. The nurse is preparing to assist the client with their first oral meal. Which of the following actions should the nurse take to promote safety? (Select all that apply)

  1. Elevate the head of the bed to a high-Fowler's position before starting the meal.Answer
  2. B
    Provide a drinking straw to help the client easily consume thin liquids.
  3. Encourage the client to tuck their chin downward toward their chest when swallowing.Answer
  4. D
    Lower the head of the bed to a flat, supine position immediately after the meal to promote rest.
  5. Ensure that functioning suction equipment is readily available at the client's bedside.Answer
  6. F
    Assign an unlicensed assistive personnel to perform the initial feeding to assess the client's tolerance.

Answer

The nurse should elevate the head of the bed to a high-Fowler's position, encourage the use of a chin-tuck maneuver, and ensure suction equipment is available at the bedside.
For a client with dysphagia, basic care centers on protecting the airway and facilitating safe nutrition. Elevating the head of the bed to a high-Fowler's position uses gravity to help food travel down the esophagus. Instructing the client to tuck their chin while swallowing physically narrows the trachea opening, providing additional protection against aspiration. Finally, having suction equipment immediately available is an essential proactive safety measure in case a choking emergency occurs.

Step-by-Step Solution

1
Identify the client's condition and associated risks.
The client is post-operative with dysphagia, making airway compromise and aspiration the highest priority concerns during oral intake.
Recognizing the risk of aspiration guides the selection of safe feeding interventions.
2
Determine appropriate positioning for the meal.
The client must be seated fully upright (high-Fowler's) during the meal and use physical techniques like a chin-tuck to swallow.
Upright positioning and airway-narrowing techniques physically prevent food and fluid from entering the trachea.
3
Evaluate the safety and appropriateness of additional interventions.
Suction must be present for emergencies. Straws, thin liquids, supine positioning, and delegating the initial assessment must be avoided.
Basic care must prioritize Airway, Breathing, and Circulation (ABCs) and remain strictly within the nurse's scope of practice.

Key Concept

Basic Care and Comfort: Dysphagia Precautions
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Topics

Basic Care and Comfort

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