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Zorluk: OrtaBasic Care and Comfort

A practical nurse is assisting a client with right-sided weakness and a history of dysphagia to eat their prescribed pureed meal. During the meal, the client begins to cough continuously and their voice sounds noticeably wet and gurgly. Which of the following is the priority action for the nurse to take?

  1. Stop the feeding immediately and ensure the client remains in a high upright position.Cevap
  2. B
    Offer the client a small sip of thickened liquid to help clear their airway.
  3. C
    Auscultate the client's lung sounds bilaterally to assess for pulmonary aspiration.
  4. D
    Lower the head of the bed to a semi-Fowler's position to promote relaxation.

Cevap

Stop the feeding immediately and ensure the client remains in a high upright position.
A continuous cough and a wet, gurgly voice during a meal are critical indicators of potential aspiration. The immediate priority is to stop the intake of food to protect the airway and keep the client upright to prevent further aspiration.

Adım Adım Çözüm

1
Identify the clinical signs presented in the scenario.
The client has a continuous cough and a wet, gurgly voice while eating.
Recognizing these symptoms is essential to identify active aspiration in a client with known dysphagia.
2
Apply the principles of airway, breathing, and circulation (ABC) prioritization.
The airway is currently compromised by the food intake.
In any emergency or potential emergency, protecting the airway is the absolute first priority.
3
Determine the most appropriate immediate nursing intervention.
The nurse must immediately halt the feeding process and maintain the client in a safe, upright position.
Stopping the meal removes the source of the aspiration, and an upright position uses gravity to help prevent further material from entering the trachea.

Anahtar Kavram

Aspiration Precautions and Airway Prioritization in Dysphagia
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Konular

Basic Care and Comfort

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