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Zorluk: OrtaBasic Care and Comfort

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.

  1. Provide oral hygiene every few hours using moistened sponge swabs to maintain mucous membrane moisture.Cevap
  2. B
    Place the client in a completely flat, supine position for resting immediately after oral intake.
  3. C
    Direct the unlicensed assistive personnel (UAP) to conduct the first feeding to evaluate the client's risk for choking.
  4. Ensure the client is positioned upright at a 45- to 90-degree angle while eating or drinking.Cevap
  5. E
    Apply bilateral soft wrist restraints promptly so the continuous IV infusion is not disrupted.
  6. Implement a regular toileting schedule every 2 hours while the client is awake to manage incontinence and protect skin integrity.Cevap

Cevap

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.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and identify specific risks.
The client has a diagnosis of aspiration pneumonia, underlying dementia, poor appetite, and is exhibiting restless behavior by pulling at the IV line.
Identifying specific vulnerabilities guides the prioritization of safe and effective basic care interventions.
2
Evaluate each potential intervention against fundamental safety and comfort principles.
Upright positioning, oral care, and toileting schedules safely promote hygiene and comfort. Applying restraints, delegating initial assessments, and using flat positioning violate clinical safety standards.
Nursing actions must prioritize airway protection, maintain skin integrity, and utilize the least restrictive environment.

Anahtar Kavram

Basic Care and Comfort - Interventions for Aspiration Risk, Skin Integrity, and Safety
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Konular

Basic Care and Comfort

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