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Question

Difficulty: EasyBasic Care and Comfort

A nurse is caring for a client with dysphagia who is preparing to eat breakfast. Which positioning action is most appropriate to prevent aspiration?

  1. Position the client in an upright, seated position at a 90-degree angle.Answer
  2. B
    Instruct the client to tilt their head slightly backward when swallowing.
  3. C
    Place the client in a 30-degree semi-Fowler's position during the meal.
  4. D
    Lower the head of the bed flat immediately after the client finishes eating.

Answer

Position the client in an upright, seated position at a 90-degree angle.
Sitting completely upright at a 90-degree angle (High-Fowler's position) uses gravity to help move food down the esophagus and provides the best anatomical alignment to protect the airway from aspiration during a meal. This is the standard baseline intervention for any client at risk for aspiration.

Step-by-Step Solution

1
Identify the primary risk factor for the client.
The client has dysphagia (difficulty swallowing), which inherently increases the risk of choking and pulmonary aspiration.
Swallowing difficulties impair the normal physiological mechanisms that protect the airway during oral intake.
2
Determine the safest physical alignment for oral intake.
A 90-degree upright position (High-Fowler's) is required during meals.
This specific position utilizes gravity to facilitate the movement of food into the esophagus while keeping the trachea structurally protected.

Key Concept

Aspiration Precautions and Positioning
Estimated Time:45s
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Topics

Basic Care and Comfort

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