The nurse instructs the unlicensed assistive personnel to feed an older adult. If the nurse is unable to observe feeding directly, which action should the nurse use to assess the older adult's risk for aspiration immediately following feeding?
a. Note food volume eaten
b. Observe skin color
c. Inspect for pocketing
d. Monitor for bradypnea
C
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A Incorrect. The amount of food consumed by an older adult is unrelated to the risk of aspiration so noting the amount of food eaten is unsuitable for detecting a risk for aspiration.
B Incorrect. An alteration in circulation as evidenced by a change in skin color can be a late indicator of aspiration. Thus a change in skin color can indicate the presence of aspiration, but the older adult with a change in skin color is not nec-essarily at risk for aspiration.
C Correct. The nurse is able to assess the risk for aspiration by assessing the adult for pocketing, residual accumulations or pockets of food in the mouth, which the older adult can aspirate after the meal is complete. If food is found in the mouth, the nurse removes it and evaluates the current plan of care.
D Incorrect. The nurse monitors for tachypnea as an indicator of aspiration; how-ever, tachypnea does not indicate a risk for aspiration.
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