A patient with a recent stroke coughs repeatedly while drinking water and develops a wet, gurgling voice. What should the nurse do first?
Correct answer: A. Stop oral intake and assess the patient's airway
- A. Stop oral intake and assess the patient's airway
- B. Encourage smaller sips of water through a straw
- C. Continue the drink while documenting the coughing
- D. Place food at the bedside for the patient to try later
Explanation
Coughing and a wet voice during drinking are signs of possible aspiration and impaired swallowing. Oral intake should stop while the airway and swallowing safety are assessed. A straw or continued drinking can increase the amount entering the airway.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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