A client who has advanced amyotrophic lateral sclerosis (ALS) is receiving palliative care at home. The client has dysphagia and is at risk for aspiration. The client's spouse asks the nurse how to prevent aspiration when feeding the client. Which of the following responses should the nurse make?

The nurse should instruct the spouse to position the client upright during and after feeding, as this facilitates swallowing and reduces the risk of aspiration. This is an evidence-based practice that promotes safety and comfort for the client.

Incorrect answers:

A) The nurse should not advise the spouse to thicken liquids to a honey-like consistency before giving them to the client, as this may increase the difficulty of swallowing and cause choking or aspiration. The appropriate consistency of liquids depends on the individual client's needs and preferences, and should be determined by a speech-language pathologist.

C) The nurse should not suggest that the spouse offer small bites of soft foods and encourage chewing well, as this may be too challenging for a client who has dysphagia due to ALS. The client may have impaired oral motor function and muscle weakness that prevent effective chewing and swallowing. The appropriate texture of foods depends on the individual client's needs and preferences, and should be determined by a speech-language pathologist.

D) The nurse should not recommend that the spouse check the client's mouth for pocketing of food after each bite, as this may be invasive and uncomfortable for

the client. The spouse should observe for signs of difficulty swallowing or aspiration, such as coughing, choking, drooling, or changes in voice quality.

The nurse should monitor the client's respiratory rate and level of consciousness after administering an opioid analgesic, as these are indicators of potential adverse effects such as respiratory depression and sedation. This is a priority action according to the airway, breathing, circulation (ABC) framework.

Incorrect answers:

A) The nurse should assess the client's pain level after 15 min, but this is not the priority action. The nurse should first ensure that the client's airway and breathing are not compromised by the medication.

B) The nurse should document the administration and the client's response, but this is not the priority action. Documentation is important, but it does not take precedence over monitoring for adverse effects.

D) The nurse should educate the client about nonpharmacological pain relief methods, but this is not the priority action. Education is part of holistic care, but it does not address the immediate need of managing pain and preventing complications.