Level: Clinical
Difficulty: Medium
Subtopic: Dysphagia and aspiration risk
NCLEX: A client with dysphagia coughs during sips of thin liquids and has a wet vocal quality. What is the nurse’s best…
Nutrition Basic Care and Comfort
Case Study
A client with dysphagia coughs during sips of thin liquids and has a wet vocal quality. What is the nurse's best action?
Question
A. Stop oral intake, maintain airway, and notify the provider for swallow evaluation per protocol.
B. Encourage larger sips of thin liquids to strengthen swallowing.
C. Turn the client on the side and leave to obtain a tray.
D. Document as tolerated and continue the regular diet order.
B. Encourage larger sips of thin liquids to strengthen swallowing.
C. Turn the client on the side and leave to obtain a tray.
D. Document as tolerated and continue the regular diet order.
Rationale
Correct answer: A. Stop oral intake, maintain airway, and notify the provider for swallow evaluation per protocol.
Rationale: Coughing and wet voice during swallowing suggest aspiration risk; stop oral intake and request swallow evaluation before continuing PO diet.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Coughing and wet voice during swallowing suggest aspiration risk; stop oral intake and request swallow evaluation before continuing PO diet.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.