Question

a nurse is caring for a client who is receiving enteral nutrition. the nurse should plan to monitor the client for which of the following early indications of aspiration? (select all that apply.) restlessness behavioral changes peripheral cyanosis tachypnea pulmonary abscess formation

Explanation:

• Restlessness: It can occur as the body tries to compensate for the irritation or obstruction in the respiratory tract due to aspiration.
• Behavioral changes: Such as confusion or agitation, can be an early sign as the brain is affected by the reduced oxygenation (if aspiration starts to impact gas exchange).
• Peripheral cyanosis: Occurs due to poor oxygenation of the blood. When there is aspiration, especially if it starts to interfere with normal gas exchange in the lungs, peripheral tissues may not get enough oxygenated blood, leading to cyanosis (bluish - discoloration of the skin, usually first noticeable in the extremities).
• Tachypnea (rapid breathing): While it can be a sign of aspiration, it is more of a later sign as the body tries to increase the amount of oxygen intake when gas exchange is already significantly compromised.
• Pulmonary abscess formation: This is a late complication of aspiration. It occurs after the aspiration event has led to an infection in the lung tissue, which takes time to develop.

Answer:

Restlessness, Behavioral changes, Peripheral cyanosis