Place the actions in order when a client with an acute stroke coughs during a bedside dysphagia screen.
Ordered Response
Choose your responses, then check the answer.
Explanation
Coughing and a wet voice indicate a failed screen. Stop oral intake, assess and protect breathing, keep the client upright with suction available, arrange formal evaluation, and document the findings and communication.
Correct sequence Stop PO → assess breathing → upright and clear secretions → obtain formal evaluation → document.
Why this is correct A failed dysphagia screen means the client has not demonstrated that oral intake is safe. Food, fluid, and oral medications remain withheld while the nurse assesses for aspiration and supports airway clearance. The provider and swallowing specialist are then engaged according to protocol.
NCLEX decision rule After a failed swallow screen, do not repeat oral trials or give pills to test tolerance. Protect the airway and move from screening to formal assessment.
Failed dysphagia screenThe client is awake and sitting upright but coughs and develops a wet voice after the test swallow. No food, fluid, or oral medication has otherwise been given.
Dysphagia — Impaired swallowing that can allow food, fluid, or medication to enter the airway.
NPO — Nothing by mouth, including food, fluids, and oral medication unless specifically authorized.
Speech-Language Pathology — A discipline that evaluates swallowing and communication problems.