A nurse is caring for a client with dysphagia associated with a left-sided stroke and right-sided weakness.
Which of the following strategies are appropriate to reduce the risk of aspiration?

Encourage client to tuck chin when swallowing.

Ensure that any protein is pureed prior to feeding the client.

Assess client's preferences and have their family leave snacks at their bedside.

Turn on music to promote client's relaxation.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Chin tuck alters airway mechanics, reducing aspiration risk by improving epiglottic closure and minimizing passage of food into respiratory pathways.

Choice B rationale

Pureeing protein may ease swallowing but does not inherently reduce aspiration risk compared to specific swallowing techniques.

Choice C rationale

Unsupervised snack access increases aspiration risk, as dysphagia requires monitored intake to prevent respiratory complications.

Choice D rationale

Background music may provide relaxation but does not scientifically mitigate aspiration risks in dysphagia-related interventions. .

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Correct Answer is B

Explanation

Choice A rationale

Nitroprusside is a vasodilator for hypertensive crises but is contraindicated in elevated ICP because it increases cerebral blood volume and exacerbates intracranial pressure, worsening the patient's condition.

Choice B rationale

Hypertonic saline (3%) helps reduce ICP by drawing excess fluid from brain tissue into the bloodstream through osmosis, effectively lowering intracranial pressure while maintaining cerebral perfusion.

Choice C rationale

Furosemide is a loop diuretic that reduces fluid overload but does not specifically target ICP. It is less effective in managing the osmotic balance required for intracranial pressure reduction.

Choice D rationale

Norepinephrine is a vasopressor used to treat hypotension and improve perfusion but does not lower ICP and may increase cerebral vasoconstriction, exacerbating intracranial hypertension. .

A. Hold the feeding if the client has soft brown stools and is passing flatus. B. Dilute each medication with 5% dextrose in water (D5W) and flush with at least 30 mL. C. Discuss the order with the prescriber if the client's abdomen is distended with hypoactive bowel sounds and RLQ tenderness. D. Check for residual enteral formula prior to administration.

Correct Answer is C

Explanation

Choice A rationale

Soft stools and flatus indicate proper gastrointestinal function, suggesting tolerance to feeding. With no adverse symptoms, it is not scientifically valid to hold enteral feeding based on these findings alone.

Choice B rationale

Diluting medications with D5W and flushing ensures patency but does not address potential complications like abdominal distention or bowel sounds. RLQ tenderness must first be evaluated for safety.

Choice C rationale

Abdomen distention with hypoactive bowel sounds and RLQ tenderness suggests possible ileus or bowel obstruction. Discussing this condition with the prescriber ensures safe feeding practices and prevents worsening complications.

Choice D rationale

Residual formula checks are relevant for gastric, not jejunostomy, feeding. Scientific practice discourages assessing residual in jejunostomy feeding as the tube bypasses the stomach.

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A nurse is caring for a client with dysphagia associated with a left-sided stroke and right-sided weakness.Which of the following strategies are appropriate to reduce the risk of aspiration?

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A nurse is caring for a client with dysphagia associated with a left-sided stroke and right-sided weakness.
Which of the following strategies are appropriate to reduce the risk of aspiration?