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.
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.
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