QLexNursing

🔹 The nurse notes that on Day 2 the client is “slow to respond verbally but responds appropriately,” which signals a change in neurological status compared to Day 1 when the client was fully alert and oriented with normal strength.

🔹 The client reports “feeling food stuck in their mouth” and has a hoarse vocal quality, which are classic signs of impaired swallowing (dysphagia) and possible impaired clearance of oral secretions or food.

🔹 The presence of mild left-sided weakness suggests a possible new or evolving neurologic event (e.g., stroke/TIA), which further compromises oral-motor coordination and increases the risk of aspiration during eating or drinking.

🔹 Neurological impairment often affects the swallow reflex, cough effectiveness, and ability to safely manage oral intake, greatly increasing the risk for aspiration and aspiration pneumonia.

🔹 Therefore, based on the combination of neurologic changes, swallowing complaints, and hoarseness, the most appropriate statement is that the client is at risk for aspiration as evidenced by altered neurological status and new swallowing difficulty.

Decreased platelet count

🔹 There is no data in the exhibits indicating thrombocytopenia (no CBC, no abnormal bruising/bleeding beyond expected postop ecchymosis).

🔹 The concern here is more about neurologic and swallowing changes, not abnormal platelets.

Tachycardia

🔹 The heart rate increased from 78/min to 88/min, which is still within normal limits and not diagnostic of tachycardia (>100/min).

🔹 There is no indication that tachycardia is a primary risk or problem driving the nurse’s concern.

Sepsis

🔹 The vital signs show only a slight temperature increase to 37.4°C (99.3°F) with stable BP and RR, not meeting criteria for systemic infection or sepsis.

🔹 The new findings focus on neurologic and swallowing issues, not systemic signs of infection (no high fever, hypotension, or tachypnea).

Oxygenation

🔹 The oxygen saturation decreased slightly from 100% to 96%, which is still within normal range and does not directly indicate aspiration yet.

🔹 The risk is being identified before significant oxygenation compromise occurs; it is the neuro and swallowing changes that signal the risk.

Cardiovascular findings

🔹 The blood pressure and heart rate changes are mild and do not indicate an acute cardiac event or specific cardiovascular problem.

🔹 The major concern in this scenario is not circulation, but rather the impact of neurologic change on swallowing safety.

Enoxaparin medication

🔹 Enoxaparin use does raise bleeding risk and could relate to platelet or hemorrhage concerns, but nothing in the scenario points to active bleeding or hemodynamic compromise.

🔹 It is not the main evidence for aspiration risk; the neurologic and swallowing changes are far more relevant.