A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met?

Choice A Reason:

Documenting that the nasogastric tube is in the correct place is not appropriate in this scenario. A gastric pH of 7.35 is too high for stomach contents, which typically have a pH between 1.5 and 3.5. This high pH suggests that the tube may be misplaced, possibly in the respiratory tract or another non-gastric location. Therefore, documenting the tube as correctly placed could lead to serious complications if the tube is indeed misplaced.

Choice B Reason:

Notifying the health care provider is the most appropriate action. A pH of 7.35 is indicative of a potential misplacement of the nasogastric tube. The health care provider needs to be informed immediately to take corrective actions, such as ordering an X-ray to confirm the tube’s placement or re-evaluating the tube’s position. This step is crucial to ensure patient safety and prevent complications such as aspiration pneumonia or other adverse effects.

Choice C Reason:

Checking for placement by auscultating for air injected into the tube is an outdated and unreliable method. This technique can sometimes give false assurance of correct placement, as the sound of air can be heard even if the tube is in the respiratory tract. Current best practices recommend using pH testing and radiographic confirmation for accurate placement verification.

Choice D Reason:

Retesting the pH using another strip might seem like a reasonable step, but it is not the best immediate action. If the initial pH test shows a value of 7.35, it is unlikely that retesting will yield a significantly different result. The priority should be to notify the health care provider to address the potential misplacement promptly.

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Choice A Reason:

Telling his wife what the client needs is not the most effective discharge action. While it is important for the wife to understand the client’s needs, this approach is too passive and does not actively engage the client or his wife in the care process. Effective management of Parkinson’s disease requires active participation from both the client and the caregiver to ensure adherence to the care plan and to address any concerns or preferences they may have.

Choice B Reason:

Setting up visitations by a home health nurse can be beneficial, but it is not the most effective discharge action on its own. Home health nurses can provide valuable support and monitoring, but the success of the management plan also depends on the involvement and commitment of the client and his wife. Without their active participation, the care plan may not be fully effective.

Choice C Reason:

Involving the client and his wife in developing a plan of care is the most effective discharge action. This approach ensures that both the client and his wife are fully engaged in the care process, understand the management plan, and are more likely to adhere to it. Collaborative care planning allows for the consideration of the client’s and caregiver’s preferences, needs, and concerns, leading to a more personalized and effective care plan. This active involvement can also empower the client and his wife, improving their confidence in managing the disease.

Choice D Reason:

Writing up a detailed plan of care according to standards is important, but it is not the most effective discharge action if done in isolation. A standardized care plan may not address the unique needs and preferences of the client and his wife. Without their involvement in the development of the plan, there may be a lack of understanding or commitment to the care plan, reducing its effectiveness. Personalizing the care plan through active involvement of the client and his wife is crucial for successful management.