Which nursing action is a priority in the client at risk for respiratory aspiration?
A) Orient the client to person, place, and time.
B) Position the client with the head of the bed at 45 degrees.
C) Administer intravenous antibiotics, as ordered.
D) Encourage cough and deep breathing exercises.
B) Position the client with the head of the bed at 45 degrees.
Explanation: A) While all the listed nursing actions are appropriate for a client at risk for aspiration, the priority is given to keeping the head of the bed elevated. The risk for aspiration is greatly increased with a decreased level of consciousness and in a recumbent individual, whose more vertical airways in the right lung provide more direct paths to the posterior segment of the upper lobe or the apical segments of the lower lobe.
B) While all the listed nursing actions are appropriate for a client at risk for aspiration, the priority is given to keeping the head of the bed elevated. The risk for aspiration is greatly increased with a decreased level of consciousness and in a recumbent individual whose more vertical airways in the right lung provide more direct paths to the posterior segment of the upper lobe or the apical segments of the lower lobe.
C) While all the listed nursing actions are appropriate for a client at risk for aspiration, the priority is given to keeping the head of the bed elevated. The risk for aspiration is greatly increased with a decreased level of consciousness and in a recumbent individual whose more vertical airways in the right lung provide more direct paths to the posterior segment of the upper lobe or the apical segments of the lower lobe.
D) While all the listed nursing actions are appropriate for a client at risk for aspiration, the priority is given to keeping the head of the bed elevated. The risk for aspiration is greatly increased with a decreased level of consciousness and in a recumbent individual whose more vertical airways in the right lung provide more direct paths to the posterior segment of the upper lobe or the apical segments of the lower lobe.
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