A nurse is caring for a client who has dysphagia and has difficulty swallowing during meals. Which of the following actions should the nurse take to reduce the client's risk of aspiration?
Add liquid to foods to thin consistency.
Tilt the client's head slightly backward.
Encourage socialization with others during meals.
Provide mouth care before the client eats.
The Correct Answer is D
A. Add liquid to foods to thin consistency.: Thin liquids are actually the most difficult to swallow and increase the risk of aspiration. Foods should be thickened to a "nectar" or "honey" consistency as prescribed.
B. Tilt the client's head slightly backward.: This opens the airway. For safe swallowing, the client should use the "chin-tuck" method (tilting the head forward/down) to help close the trachea and open the esophagus.
C. Encourage socialization with others during meals.: Clients with dysphagia should focus entirely on chewing and swallowing to prevent aspiration; talking while eating increases risk.
D. Provide mouth care before the client eats.: Oral hygiene before meals stimulates the appetite and removes bacteria from the mouth. If a client does aspirate, they are less likely to develop pneumonia if their oral cavity is clean.
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Related Questions
Correct Answer is D
Explanation
A. Add liquid to foods to thin consistency.: Thin liquids are actually the most difficult to swallow and increase the risk of aspiration. Foods should be thickened to a "nectar" or "honey" consistency as prescribed.
B. Tilt the client's head slightly backward.: This opens the airway. For safe swallowing, the client should use the "chin-tuck" method (tilting the head forward/down) to help close the trachea and open the esophagus.
C. Encourage socialization with others during meals.: Clients with dysphagia should focus entirely on chewing and swallowing to prevent aspiration; talking while eating increases risk.
D. Provide mouth care before the client eats.: Oral hygiene before meals stimulates the appetite and removes bacteria from the mouth. If a client does aspirate, they are less likely to develop pneumonia if their oral cavity is clean.
Correct Answer is C
Explanation
A. Ask the assistive personnel to document the client's time of death.: Documenting the time of death is a legal responsibility that must be performed by the nurse or the provider who pronounces the death.
B. Wear sterile gloves when cleaning the client's body.: Sterile gloves are not required for postmortem care; clean (non-sterile) gloves are part of standard precautions.
C. Place an identification tag on the outside of the client's shroud.: Proper identification is a standard part of postmortem care. One tag is typically placed on the client's toe/ankle and another on the outside of the shroud or body bag.
D. Remove the client's dentures and give them to the client's family.: For a client requiring an autopsy, all tubes, lines, and sometimes dentures are often left in place. Furthermore, dentures should typically stay with the body to maintain the natural shape of the face.
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