The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider?

Choice A Reason: This is incorrect because observing the client swallowing small sips of water before assisting with feeding may not reduce the risk of aspiration pneumonia. Water is a thin liquid that can easily enter the lungs if the client has impaired swallowing or cough reflexes. The nurse should assess the client's need for thickened liquids or pureed foods and use a swallow screening tool to determine the appropriate consistency and amount of food and fluids.

Choice B Reason: This is incorrect because turning on the television for the client during meals may increase the risk of aspiration pneumonia. Television can distract the client from focusing on chewing and swallowing and cause them to eat too fast or too much. The nurse should provide a quiet and calm environment for the client during meals and encourage them to eat slowly and carefully.

Choice C Reason: This is incorrect because instructing the client to tilt their head back while swallowing may increase the risk of aspiration pneumonia. Tilting the head back can open the airway and allow food or fluids to enter the lungs. The nurse should instruct the client to tilt their head forward or tuck their chin while swallowing, which can close the airway and prevent aspiration.

Choice D Reason: This is correct because sitting the client upright 90 degrees then assisting the client with feeding can reduce the risk of aspiration pneumonia. Sitting upright can help gravity move food and fluids down the esophagus and away from the lungs. The nurse should also keep the client upright for at least 30 minutes after eating and drinking to prevent regurgitation and aspiration.

Choice A Reason: The client needs total nursing care is the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which is a tool that measures the level of consciousness based on eye opening, verbal response, and motor response. A score of 6 indicates severe brain injury and coma, meaning that the client is unresponsive and dependent on others for all activities of daily living.

Choice B Reason: Indicates stable neurologic status is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A stable neurologic status means that there are no changes in the level of consciousness, vital signs, or neurological signs.

Choice C Reason: The client has a decline in level of consciousness but is able to protect his airway is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A decline in level of consciousness means that the client is less alert and responsive than normal, but still able to respond to stimuli and maintain airway patency.

Choice D Reason: The client is alert and oriented is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. Alert and oriented means that the client is fully awake and aware of person, place, time, and situation.