The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care.

Which of the following interventions should the nurse plan to implement? Select all that apply.

Choice A rationale:

Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.

Choice B rationale:

A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.

Choice C rationale:

A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.

Choice D rationale:

Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.

The correct answer is **b. A room containing personal belongings.**

Choice A rationale:

A room without a window would not be a therapeutic environment for a cognitively impaired client. Lack of natural light and connection to the outside world can be disorienting and distressing for these patients.

Choice B rationale:

A room containing personal belongings is the most therapeutic environment for a cognitively impaired client. Familiar objects and surroundings can help provide a sense of comfort, security, and orientation. This can reduce agitation and confusion, which are common issues for cognitively impaired patients.

Choice C rationale:

A room adjacent to the nursing station may not be the most therapeutic environment. While proximity to staff can be beneficial, the increased noise and activity level near the nursing station could be overstimulating and disruptive for a cognitively impaired client.

Choice D rationale:

A room with dim lighting is not ideal for a cognitively impaired client. Adequate lighting is important to help these patients maintain orientation and avoid falls or other safety issues. Dim lighting can contribute to confusion and disorientation.