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Difficulty: MediumBasic Care and Comfort

A client recovering from an ischemic stroke has residual dysphagia and requires assistance with oral intake. The nurse is planning interventions to prevent complications during feeding. Which of the following actions is the most appropriate for the nurse to implement?

  1. A
    Document occasional coughing during the meal as a normal physiological change of aging that does not require further assessment.
  2. Maintain the client in a high-Fowler's position for 30 to 45 minutes following the completion of the meal.Answer
  3. C
    Hyperextend the client's neck slightly when offering oral fluids to help gravity move the liquid down the esophagus.
  4. D
    Delegate the initial oral feeding and the evaluation of the client's swallowing tolerance to the unlicensed assistive personnel (UAP).

Answer

The most appropriate action is to maintain the client in an upright, high-Fowler's position for 30 to 45 minutes after the meal.
Keeping the client in a high-Fowler's position (at least 90 degrees) for 30 to 45 minutes after eating uses gravity to facilitate the passage of food through the gastrointestinal tract and significantly reduces the risk of gastroesophageal reflux and subsequent aspiration.

Step-by-Step Solution

1
Identify the client's primary risk factor based on the clinical presentation.
The client has dysphagia following a stroke, placing them at high risk for aspiration pneumonia.
Recognizing the primary safety risk dictates which basic care and comfort interventions must be prioritized.
2
Select the intervention that directly mitigates the identified risk.
The nurse chooses to position the client upright after eating.
Maintaining a high-Fowler's position utilizes gravity to prevent the backflow of gastric contents, effectively protecting the airway.

Key Concept

Aspiration Precautions and Safe Positioning
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Topics

Basic Care and Comfort

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