FUNDS: Aspiration

A nurse is caring for a client who has just finished eating. While talking to the nurse, the client's voice sounds "wet" and gurgling. Which action should the nurse take first? Contact the healthcare provider. Place the client on nothing by mouth (NPO) status. Document the amount of food consumed. Ask the client to clear their throat and take small sips of water, then reassess​.

Place the client on nothing by mouth (NPO) status. Document the amount of food consumed.

A nurse is caring for a client who has just returned from the post-anesthesia care unit (PACU) after a surgical procedure. The client is arousable but very drowsy and slurs words when asking for water. Which action by the nurse is most appropriate? Ask the client if they would like to eat a snack. Withhold all food and fluids until the client is awake and alert. Offer the client small sips of water without a straw. Sit the client upright and provide water through a straw.

Withhold all food and fluids until the client is awake and alert.

A nurse is caring for several clients at risk for aspiration. Which information should the nurse consider when planning care? Select all that apply. Only clients with dysphagia are at risk for aspiration. All older adults are at risk for aspiration. Aspiration can be silent without common symptoms. The body is not functioning properly when aspiration occurs. Aspiration means that food or water enters the trachea instead of the stomach.

Aspiration can be silent without common symptoms. The body is not functioning properly when aspiration occurs. Aspiration means that food or water enters the trachea instead of the stomach.

​The nurse is caring for a client and suspects dysphagia. Which are the general symptoms of aspiration? Coughing or choking while drinking Epigastric pain within 60 minutes of eating Drop in oxygen saturation while eating Pocketing food Wheezing breath sounds

Coughing or choking while drinking Drop in oxygen saturation while eating Pocketing food Wheezing breath sounds

A nurse is caring for a client admitted with left-sided weakness and facial drooping for 3 days. Which nursing actions will protect the client's airway while eating and drinking? Select all that apply. Withhold fluids until food is consumed. Encourage the client to take large bites. Do not provide a straw for drinking. Position the client left-side lying after eating. Position the client upright when eating. Avoid talking to the client while they are eating.

Do not provide a straw for drinking. . Position the client upright when eating. Avoid talking to the client while they are eating.

A nurse is caring for a client with prescribed aspiration precautions. What is the main concern when a client has pockets of food remaining in the mouth after eating? Pocketing is a sign of drowsiness or disorientation. The pocket of food may not have been chewed up properly. Eventually, the pocket of food may be aspirated into the airway. The food left in the mouth will make speech and communication difficult.

Eventually, the pocket of food may be aspirated into the airway.

The nurse is caring for a client with an increased risk for aspiration. Which actions should the nurse take? Select all that apply. ​Monitor oxygen saturation during feeding. Avoid mixing foods of different textures in the same mouthful. ​ Tilt the head backward when swallowing liquid. ​ Position the client upright (45-90 degrees) during feedings. ​ Maintain an upright position for at least 30 minutes after a meal. ​

Monitor oxygen saturation during feeding. Avoid mixing foods of different textures in the same mouthful. ​ ​ Position the client upright (45-90 degrees) during feedings. ​ Maintain an upright position for at least 30 minutes after a meal. ​

A nurse is caring for an older adult client who is retired but very active in the community. The client exercises daily and enjoys cooking healthy meals with their partner. Is this client at risk for aspiration? No, because the partner likely monitors the client while eating. Yes, because of the client's age. Yes, because of the client's active lifestyle. No, because the client has no risk factors for aspiration.

No, because the client has no risk factors for aspiration.

A nurse is caring for an older adult client with muscular dystrophy in the emergency department (ED). The client's speech is abnormal, and lip and tongue movements appear delayed. The client has lost 7 pounds in the past 2 weeks. Secretions are thick, and the skin appears rough and dry. Which is the priority action taken by the nurse? Offer the client water to drink through a straw. The client is malnourished, so prepare to feed the client immediately. Place the client on nothing by mouth (NPO) status and notify the healthcare provider. Document the findings as common symptoms of muscular dystrophy.

Place the client on nothing by mouth (NPO) status and notify the healthcare provider.

A nurse is caring for a toddler with cerebral palsy who has limited communication and impaired mobility of the lips and tongue. Which instructions should be provided to the toddler's caregiver? Select all that apply. Thicken liquids to prescribed consistency. Provide small, easy to swallow bites. Assure correct positioning when feeding. Monitor weight daily to ensure adequate intake. Instruct that drooling and gagging are expected.

Thicken liquids to prescribed consistency. Provide small, easy to swallow bites. Assure correct positioning when feeding. Monitor weight daily to ensure adequate intake.