Author Question: The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action ... (Read 161 times)

09madisonrousseau09 · **on:** Jun 25, 2018

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?

a. Turn and reposition immobile patients at least every 2 hours.
b. Place patients with altered consciousness in side-lying positions.
c. Monitor for respiratory symptoms in patients who are immunosuppressed.
d. Insert nasogastric tube for feedings for patients with swallowing problems.

Question 2

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?

a. I will call the doctor if I still feel tired after a week.
b. I will continue to do the deep breathing and coughing exercises at home.
c. I will schedule two appointments for the pneumonia and influenza vaccines.
d. I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks.

abctaiwan · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications.

Answer to Question 2

ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.