A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing interventions might be recommended to help prevent aspiration during eating? Select all that apply. (Select All that Apply.)

Have the patient swallow twice after each bite.

Place the patient in a semi-Fowler position.

Provide clear liquids only until the patient can swallow solid foods.

Check the patient's mouth for pocketing of food.

Encourage the use of a straw for liquids.

Place food on the unaffected side of the patient's mouth.

Answer and Explanation

Correct Answer : A,D,F

A. Have the patient swallow twice after each bite: This can help clear any residual food from the mouth and reduce the risk of aspiration.
B. Place the patient in a semi-Fowler position: This position is not ideal for preventing aspiration. The patient should be in an upright, high Fowler’s position to minimize the risk.
C. Provide clear liquids only until the patient can swallow solid foods: Clear liquids can actually be more difficult to control in the mouth and throat than thicker liquids and may increase the risk of aspiration.
D. Check the patient's mouth for pocketing of food: Ensuring that no food is left in the mouth can help prevent aspiration after the patient has finished eating.
E. Encourage the use of a straw for liquids: Using a straw can increase the risk of aspiration because it delivers liquids quickly and may overwhelm the swallowing mechanism, especially in patients with dysphagia.
F. Place food on the unaffected side of the patient's mouth: This helps ensure that the stronger side of the mouth and throat manages the food, reducing the risk of aspiration.

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Correct Answer is A

Explanation

A. TIA: A transient ischemic attack (TIA) is characterized by temporary symptoms due to a brief period of reduced blood flow to the brain, with no lasting damage.
B. Stroke: A stroke involves a more prolonged interruption of blood flow to the brain and typically results in permanent neurological damage.
C. CVA: Cerebrovascular accident (CVA) is another term for stroke, involving sustained damage.
D. OSAH: This is not a relevant term or acronym for the condition described. It is not related to cerebral circulation impairment.

A. Assist the patient to turn to her side. B. Give an antiemetic as ordered. C. Perform a test for blood on the emesis. D. Call for an aide to get suction set up.

Correct Answer is A

Explanation

A. Assist the patient to turn to her side: This is the priority action to prevent aspiration of vomitus, which can be a serious complication for stroke patients who may have impaired swallowing and a reduced gag reflex.
B. Give an antiemetic as ordered: While important, administering an antiemetic should come after ensuring the patient’s safety and preventing aspiration.
C. Perform a test for blood on the emesis: This is not the immediate priority. Preventing aspiration is the first concern.
D. Call for an aide to get suction set up: Suction may be necessary if the patient is at risk of aspiration, but the first step is to turn the patient to prevent choking and aspiration.

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A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing interventions might be recommended to help prevent aspiration during eating? Select all that apply. (Select All that Apply.)

Nursing Test Bank

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Correct Answer is A

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