NCLEX-PN® ExaminationPhysiological AdaptationEasy
A client is admitted with a suspected CVA (Cerebrovascular Accident) and is experiencing right-sided weakness and expressive aphasia. The nurse understands the importance of maintaining a patent airway. Which of the following is the most appropriate initial nursing intervention to prevent aspiration?
- APosition the client with the head of the bed elevated 30-45 degrees.
- BInsert an oropharyngeal airway.
- CEncourage the client to drink thickened liquids only.
- DAdminister a prescribed antiemetic.
Show answer & explanationAnswer & explanation
Correct answer: A. Position the client with the head of the bed elevated 30-45 degrees.
Clients with CVA, especially those with expressive aphasia and weakness, are at high risk for aspiration due to impaired swallowing and gag reflex. Elevating the head of the bed to 30-45 degrees helps prevent aspiration by utilizing gravity to keep stomach contents and oral secretions from entering the airway.
Why the other options are wrong
- B. An oropharyngeal airway is used to maintain an open airway in unconscious clients by preventing the tongue from falling back, not primarily for aspiration prevention in a conscious client who may have a gag reflex.
- C. While thickened liquids are important for feeding, the immediate priority is general aspiration prevention, and feeding should only occur after a thorough swallow assessment.
- D. Antiemetics prevent vomiting, but aspiration can occur from impaired swallowing of saliva or food, even without vomiting.
CVA Aspiration Prevention
Clients with CVA are at high risk for aspiration due to neurological deficits affecting swallowing and airway protection. Initial interventions focus on positioning and careful assessment.
- Neurological deficits post-CVA impair swallowing and gag reflex.
- Elevating the head of the bed is a primary non-pharmacological intervention.
- A swallow screen should be performed before oral intake.
Memory trick: Head of bed up high, keeps the lungs dry!