The nurse instructs the unlicensed assistive personnel to feed an older adult. If the nurse is unable to observe feeding directly, then which action should the nurse use to assess the older adult's risk for aspiration immediately after feeding?

Question

a. Note food volume eaten. c. Inspect for pocket-ing.
b. Observe skin color. d. Monitor for bra-dypnea.

Answer 1

C
The nurse is able to assess the risk for aspiration by assessing the adult for pocketing, which is residual accumulations or pockets of food in the mouth that the older adult can aspirate after the meal is complete. If food is found in the mouth, then the nurse removes it and evaluates the cur-rent plan of care. The amount of food consumed by an older adult is unrelated to the risk of aspi-ration; therefore noting the amount of food that is eaten is unsuitable for detecting the risk for aspiration. An alteration in circulation as evidenced by a change in skin color can be a late indi-cator 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 necessarily at risk for aspiration. The nurse monitors for tachypnea as an indicator of aspiration; however, tachypnea does not indicate a risk for aspiration.