A 72-year-old client with a history of moderate dementia is hospitalized for treatment of aspiration pneumonia. The client is receiving continuous intravenous (IV) fluids, has a poor appetite, and exhibits increased restlessness, repeatedly pulling at the IV tubing. Which of the following nursing actions are appropriate to promote the client's basic care and comfort? Select all that apply.
- Provide oral hygiene every few hours using moistened sponge swabs to maintain mucous membrane moisture.Answer
- BPlace the client in a completely flat, supine position for resting immediately after oral intake.
- CDirect the unlicensed assistive personnel (UAP) to conduct the first feeding to evaluate the client's risk for choking.
- Ensure the client is positioned upright at a 45- to 90-degree angle while eating or drinking.Answer
- EApply bilateral soft wrist restraints promptly so the continuous IV infusion is not disrupted.
- Implement a regular toileting schedule every 2 hours while the client is awake to manage incontinence and protect skin integrity.Answer
Answer
The appropriate actions are providing frequent oral hygiene, ensuring an upright position during oral intake, and implementing a regular toileting schedule.
The correct interventions prioritize physiological integrity, safety, and comfort. Providing frequent oral hygiene maintains mucous membrane moisture and reduces the risk of further respiratory infections. Ensuring the client is positioned upright at a 45- to 90-degree angle during intake utilizes gravity to prevent aspiration, which is critical given the current diagnosis. Implementing a regular toileting schedule proactively manages incontinence caused by IV fluids and dementia, protecting skin integrity and promoting dignity.
Step-by-Step Solution
Key Concept
Basic Care and Comfort - Interventions for Aspiration Risk, Skin Integrity, and Safety