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Zorluk: OrtaAccident, Error, and Injury Prevention

A registered nurse is developing a safety care plan for an older adult client who has severe dysphagia following an ischemic stroke. Which intervention is the priority to include in the plan to prevent a life-threatening injury?

  1. A
    Delegate the initial assessment of the client's swallowing ability to an experienced unlicensed assistive personnel (UAP).
  2. Maintain the client in a high-Fowler's position during meals and for at least 30 minutes after eating.Cevap
  3. C
    Document the client's frequent coughing during meals as a normal physiological change associated with aging.
  4. D
    Prioritize the rapid administration of clear, thin liquids to ensure hydration before offering solid foods.

Cevap

Maintain the client in a high-Fowler's position during meals and for at least 30 minutes after eating.
For a client with severe dysphagia, the primary safety goal is preventing aspiration, which directly compromises the airway. Sitting the client upright in a high-Fowler's position (at least 90 degrees) during the meal and keeping them upright for 30 to 45 minutes afterward utilizes gravity to facilitate proper swallowing and prevents gastric reflux. This direct intervention protects the airway and prevents life-threatening respiratory complications.

Adım Adım Çözüm

1
Analyze the client's condition and the primary risk factor.
The client has severe dysphagia (difficulty swallowing) post-stroke.
Dysphagia places the client at a high risk for aspiration, which can lead to airway obstruction or aspiration pneumonia.
2
Evaluate the options against airway safety (ABCs) and injury prevention protocols.
Positioning the client upright uses gravity to protect the airway.
The high-Fowler's position is the universally accepted standard of care to prevent aspiration in clients with swallowing deficits.
3
Eliminate unsafe or incorrect practices.
Delegating assessments, ignoring coughing, and providing thin liquids are all unsafe.
These actions increase the risk of aspiration or represent a failure of the nurse's duty to assess and prioritize the airway.

Anahtar Kavram

Aspiration Prevention and Airway Safety
Tahmini Süre:1m 15s
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Konular

Accident, Error, and Injury Prevention

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