An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?

Question

Quizplus · Accepted Answer

Clients with decreased level of consciousness may not be alert enough to protect their own airways; therefore, a side lying or lateral position is used to decrease the risk for developing aspiration pneumonia. If vomiting were to occur, this position promotes drainage of emesis out of the mouth instead of down the pharynx where it can be aspirated into the lungs. Maintaining an upright position during and after meals will allow remaining food particles to clear from the pharynx. (Option A) Assessing breath sounds can help identify the presence of pneumonia (eg, diminished, bronchial, crackles) but does not prevent the client from aspirating. (Option C) Titrating oxygen to maintain saturation ≥93% provides for adequate oxygenation but does not prevent the client from aspirating. (Option D) Turning and repositioning every 2 hours helps to prevent stasis of secretions in the lungs but does not prevent the client from aspirating. Educational objective: Placing a client with a decreased level of consciousness in a position that uses gravity to help drain oropharyngeal and gastric secretions can be effective in preventing aspiration and reducing the risk for aspiration pneumonia.

An 86-Year-Old Client with Diabetes and Gastroparesis Has Had Repeated