A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

A history of gastroesophageal reflux disease.

A residual of 65 mL. 1 hr postprandial.

Sitting in high-Fowler's position during the feeding

Receiving a high-osmolarity formula.

Answer and Explanation

The Correct Answer is A

A. A history of gastroesophageal reflux disease: This factor places the client at a higher risk for aspiration. Patients with gastroesophageal reflux disease (GERD) may experience backflow of stomach contents, which can lead to aspiration, especially when receiving enteral feedings.

B. A residual of 65 mL, 1 hr postprandial: While monitoring residual volumes is important to assess tolerance to feeding, a residual of 65 mL alone does not inherently indicate a high risk for aspiration. It may suggest that the feeding rate needs adjustment but isn't a direct risk factor.

C. Sitting in high-Fowler's position during the feeding: This position is actually protective against aspiration, as it promotes better gastric emptying and reduces the likelihood of reflux.

D. Receiving a high-osmolarity formula: While high-osmolarity formulas can sometimes lead to gastrointestinal discomfort or diarrhea, they do not directly increase the risk of aspiration. Proper management of feeding administration is key.

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Correct Answer is C

Explanation

A. "You are making progress in your treatment plan." While this response provides positive reinforcement, it doesn't address the client's feelings of frustration or desire to go home, potentially invalidating their emotions.

B. "You should call your partner to discuss this." Suggesting that the client call their partner shifts the focus away from their feelings and may not provide the immediate emotional support they need.

C. "It must be very frustrating for you to be here." This response acknowledges the client's feelings and validates their frustration. It opens the door for further discussion about their emotions, helping the client feel heard and understood.

D. "It would be best to discuss your feelings with your provider." This response may dismiss the client's current feelings by directing them away from the nurse, who is present and capable of providing support. It is important to validate the client's feelings first.

A. "Information Technology will install a firewall to secure client information." B. "Documentation of sensitive material is performed by the charge nurse." C. "You will be given access to the medical records of every client in the facility." D. "You will be asked to change your password once per year."

Correct Answer is A

Explanation

A. "Information Technology will install a firewall to secure client information.": This statement is appropriate as it highlights the importance of cybersecurity measures, such as firewalls, in protecting client information within a computerized documentation system.

B. "Documentation of sensitive material is performed by the charge nurse.": This statement is misleading. While charge nurses may have responsibilities for certain documentation, all licensed nurses are responsible for accurately documenting sensitive materials related to their own patient care.

C. "You will be given access to the medical records of every client in the facility.": This is incorrect. Access to client medical records should be based on the nurse's role and the specific clients they are caring for, adhering to confidentiality and privacy policies.

D. "You will be asked to change your password once per year.": This is not sufficient for maintaining security. Best practices typically recommend changing passwords more frequently (e.g., every 3-6 months) to enhance security and protect sensitive information.

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A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

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Naxlex Comprehensive Predictor Exams

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