# A 70-year-old client recovering from a left middle cerebral artery stroke has cleared an SLP bedside swallow evaluation for a dysphagia diet with pureed solids and nectar-thick liquids. Which intervention should the nurse implement to reduce aspiration risk during meals?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=363211&lang=en  
> language: en  
> subject: Nutrition and Oral Hydration  
> category: BCC

## Question

A 70-year-old client recovering from a left middle cerebral artery stroke has cleared an SLP bedside swallow evaluation for a dysphagia diet with pureed solids and nectar-thick liquids. Which intervention should the nurse implement to reduce aspiration risk during meals?

## Option

1. Place the client in a supine position with the head of the bed at 30 degrees and use a small spoon to deliver food
2. Provide water and other thin liquids at the beginning of the meal to stimulate the swallow reflex
3. Have the client sit upright at 90 degrees with the chin tucked toward the chest while swallowing **✔ Correct answer**
4. Allow the client to eat meals without direct supervision while the nurse observes periodically from the doorway

**Correct answer: 3**

## Explanation

Aspiration prevention in dysphagia rests on three pillars: upright positioning at 90 degrees, chin-tuck swallow maneuver, and thickened liquids when the SLP recommends them. Sitting upright with the chin tucked narrows the airway entrance, widens the vallecular space, and redirects the bolus toward the esophagus rather than the trachea. Supine feeding, thin liquids, and unobserved feeding all increase aspiration risk.

## In-depth explanation

Clinical Judgment
Post-stroke dysphagia carries high aspiration risk. Aspiration prevention bundle: upright 90 degrees, chin-tuck swallow, thickened liquids per SLP, and direct nurse observation. Thin liquids carry the highest aspiration risk in this population.

Memory Tip
Sit up — chin down — swallow twice — stay 30 min after meal

KR vs US
ASHA (US) and Korean stroke rehab guidelines align: SLP bedside swallow screen for every stroke client before oral intake; modified diet according to penetration-aspiration scale; HOB elevated for 30-60 min after meals.

## Clinical scenario

Clinical Practice Guide
ASHA dysphagia management standards:
- Upright 90 degrees during meals; HOB elevated 30-60 min after.
- Chin-tuck swallow narrows airway entrance and protects the trachea.
- Diet texture per SLP penetration-aspiration scale: thin → nectar → honey → pudding-thick.
- Single, small bolus; direct observation for cough, wet voice, throat clearing.
- Oral care twice daily reduces aspiration pneumonia risk by lowering oropharyngeal bacterial load.

Caution
Silent aspiration occurs in up to 40% of stroke clients without a cough reflex. Wet or gurgly voice after swallowing, throat clearing, or unexplained low-grade fever should trigger SLP re-evaluation and consideration of NPO status.

## Key concepts

- **Aspiration pneumonia** — Pneumonia caused by inhalation of oropharyngeal or gastric contents into the airway. Risk factors: stroke, dementia, sedation, NG tube, supine feeding. Often polymicrobial; covers anaerobes if right-sided lower lobe infiltrate.
- **Chin-tuck maneuver** — Compensatory swallow technique: client tilts head forward (chin to chest) before each swallow. Narrows the airway entrance, widens the vallecular space, and redirects bolus toward the esophagus. Reduces aspiration in many post-stroke clients.
- **Bedside swallow evaluation** — Initial dysphagia screen done by speech-language pathologist (SLP) or trained nurse. Tests cough, voice quality, oral motor function, and trial swallows. Failure triggers NPO status and instrumental study (FEES or videofluoroscopy).

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