Question

A nurses' aid has finished feeding a frail, older client and has lowered the head of the bed at the client's request for a nap. Which action by the nurse is most appropriate?

a. Document how the client tolerated the feeding and amount of intake.
b. Listen to the client's lungs and have the aid get a set of vital signs.
c. Raise the head of the client's bed to at least 30 degrees for the next hour.
d. Ask the client if he/she would like to have the ordered sleeping medication.

Answer 1

The nurse should raise the bed to at least 30 degrees post feeding to prevent aspiration pneumonia. Documenting the meal and checking vital signs are also important but secondary to the repositioning. Sleeping medication should be considered only after addressing immediate risks.

Step-by-step explanation:

The most appropriate action by the nurse after a frail, older client has been fed and requests to nap is to raise the head of the client's bed to at least 30 degrees for the next hour. This position can help prevent aspiration pneumonia by minimizing the risk of regurgitation and aspiration of stomach contents into the lungs while the client is lying down. Although documenting the intake and tolerance to feeding is also important, and listening to the client's lungs may be a good practice in general, the immediate concern after feeding a frail, older client is to ensure their airway remains clear and that there is less risk of aspiration.

Listening to the client's lungs and obtaining a set of vital signs could be performed as a follow-up after repositioning the client. Lastly, while asking about the ordered sleeping medication might be relevant, it is not the most appropriate action immediately following a meal and without addressing the risk of aspiration first.