The nurse identifies the diagnosis Risk for aspiration, related ...

[Yolanda]

The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale?
 
  1. Have suction equipment available at all times.
  2. Clear secretions from oral/nasal passageways as needed.
  3. Keep client in low-Fowler's position to prevent reflux.
  4. Provide frequent assessment for presence of obstructive material in mouth and throat.

Question 2

The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention?
 
  1. Assist client with ambulation.
  2. Ambulate with client, using a gait belt, twice daily for 15 minutes.
  3. Make sure client understands the rationale for using the gait belt.
  4. Client will ambulate in hallway twice daily.

[joanwhite]

Answer to Question 1

Correct Answer: 3
Rationale: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain why an intervention would be implemented. This intervention does not explain why it is being done.

Answer to Question 2

Correct Answer: 2
Rationale 1: This option lacks some of the required components of a well-written intervention.
Rationale 2: A well-written intervention should include a verb, conditions, and modifiers, plus a time element. Identifying what to do (ambulate), how to do it (with a gait belt), and how long (twice daily for 15 minutes) is the most precise statement.
Rationale 3: This option lacks some of the required components of a well-written intervention.
Rationale 4: Client will ambulate in the hallway is a goal statement, not an intervention.