# A 67-year-old client was extubated 20 hours ago after 6 days of mechanical ventilation for pneumonia. Since extubation the voice has been mildly hoarse and the throat is sore; breathing at rest is unlabored with no stridor, respiratory rate 18/min, and oxygen saturation 96% on 2 L/min by nasal cannula. Temperature is 37.1 C (98.8 F), and lung sounds were clear on the morning assessment. During the first breakfast tray, the client coughs after each sip of water, the voice becomes wet and gurgling after swallowing, and scrambled egg is found pocketed in the right cheek. Oxygen saturation falls to 92% during the meal and returns to 96% within 5 minutes of stopping. Oral metoprolol is due now. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617404&lang=en  
> language: en  
> subject: Nutrition and Oral Hydration  
> category: BCC

## Question

A 67-year-old client was extubated 20 hours ago after 6 days of mechanical ventilation for pneumonia. Since extubation the voice has been mildly hoarse and the throat is sore; breathing at rest is unlabored with no stridor, respiratory rate 18/min, and oxygen saturation 96% on 2 L/min by nasal cannula. Temperature is 37.1 C (98.8 F), and lung sounds were clear on the morning assessment. During the first breakfast tray, the client coughs after each sip of water, the voice becomes wet and gurgling after swallowing, and scrambled egg is found pocketed in the right cheek. Oxygen saturation falls to 92% during the meal and returns to 96% within 5 minutes of stopping. Oral metoprolol is due now. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Postextubation laryngeal edema
Aspiration pneumonia
Postextubation oropharyngeal dysphagia
Gastroesophageal reflux with regurgitation

Actions to take

Select 2
Thicken all liquids to nectar consistency now
Hold oral food, fluids, and oral medications
Request a racemic epinephrine nebulizer prescription
Request a speech-language swallow evaluation
Offer small sips through a straw between bites

Parameters to monitor

Select 2
Oxygen saturation during oral intake
Inspiratory stridor at rest
Gastric residual volume before each feeding
Serum prealbumin level
Voice quality after each swallow

## Explanation

Coughing and a wet voice with swallowing, food pocketing, and desaturation that occurs only during the meal indicate postextubation oropharyngeal dysphagia. The nurse holds all oral intake, including oral medications, and requests a speech-language swallow evaluation before any diet or texture is chosen. Oxygen saturation during intake and voice quality after swallowing show whether swallowing safety is improving. Stridor-directed or pneumonia-directed choices treat problems the data do not show.

## In-depth explanation

Quick answer
Postextubation oropharyngeal dysphagia; hold all oral intake and oral medications, request a speech-language swallow evaluation, and monitor oxygen saturation during intake and voice quality after swallowing.

Why this is correct
Prolonged intubation injures the pharynx and larynx and weakens swallowing coordination. The findings appear only with swallowing: cough after sips, a wet voice, pocketed food, and a saturation drop that resolves after the meal stops. That pattern identifies dysphagia rather than airway narrowing or established infection. Stopping oral intake removes the ongoing aspiration exposure, and the swallow evaluation determines the safe route, texture, and liquid consistency.

Easy analogy or mental picture
Think of a gate that was propped open for 6 days: it no longer closes on time, so every sip slips toward the airway until someone tests and retrains the gate.

Memory hook
Wet voice + cough with sips after the tube comes out = stop the tray, call the swallow team.

NCLEX decision rule
When a problem appears only during eating after extubation, stop oral intake first and let a formal swallow evaluation decide the diet; monitor the findings that occur with swallowing.

Why the other choices are wrong
Laryngeal edema causes stridor and distress at rest, which this client does not have, so racemic epinephrine and stridor checks target the wrong problem. Aspiration pneumonia would bring fever, new crackles, or persistent hypoxemia; saturation here recovers within minutes. Reflux regurgitation occurs after meals and while lying down, not as coughing with each sip. Thickening liquids without an evaluation is an outdated reflex that can still be unsafe, and a straw increases bolus size and speed. Gastric residual volume and prealbumin describe tube feeding tolerance and nutrition, not swallowing safety.

References
1AHRQ — Preventing Non-Ventilator Hospital-Acquired PneumoniaDysphagia screening and aspiration precautions reduce hospital-acquired pneumonia risk.
2MedlinePlus — Swallowing DisordersSigns of dysphagia include coughing or choking while eating and food remaining in the mouth.

## Clinical scenario

Scenario
A client extubated 20 hours ago coughs with water, develops a wet voice, pockets food, and desaturates only while eating; stridor and fever are absent.

## Key concepts

- **Oropharyngeal dysphagia** — Difficulty moving food or liquid from the mouth through the pharynx safely, often causing cough, wet voice, or pocketing.
- **Postextubation dysphagia** — Swallowing impairment that follows endotracheal intubation, especially after several days of ventilation.
- **Silent aspiration** — Entry of material below the vocal cords without an effective cough, detectable only by instrumental swallow testing.

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