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 must be at least 21 years of age to become an organ donor.": This is inaccurate. Individuals as young as 18 can register as organ donors, provided they meet the necessary criteria.

B) "Your name cannot be removed once you are listed on the organ donor list.": This is misleading. Individuals can remove themselves from the organ donor list if they change their minds, as long as they follow the appropriate procedures.

C) "Your desire to be an organ donor must be documented in writing.": This is the correct answer. To ensure that a person's wishes regarding organ donation are respected, it is essential that they are documented, typically through a donor card or registry.

D) "I cannot be a witness for your consent to donate.": While it is true that a nurse may not serve as a witness for consent to donate, this response does not provide the client with useful information about organ donation itself.

A. The client is observed mumbling quietly while alone in the day room. B. The client is observed displaying a shuffling gait while walking in the hall. C. The client states, "Being in the sun seems to really hurt my eyes." D. The client states, "I feel light-headed when I star up quickly."

Correct Answer is B

Explanation

A. The client is observed mumbling quietly while alone in the day room: This behavior may be related to the client’s schizophrenia and is not necessarily indicative of an adverse effect from the antipsychotic medication. It is common for individuals with schizophrenia to exhibit such behaviors, which may not require reporting.

B. The client is observed displaying a shuffling gait while walking in the hall: A shuffling gait can indicate extrapyramidal symptoms, such as Parkinsonism, which are potential adverse effects of antipsychotic medications. This observation requires immediate reporting to the provider for further assessment and potential adjustment of the medication.

C. The client states, "Being in the sun seems to really hurt my eyes": Photosensitivity can occur with some medications, including antipsychotics, but it is not as urgent an issue as extrapyramidal symptoms. While this should be documented and addressed, it does not necessarily require immediate intervention.

D. The client states, "I feel light-headed when I stand up quickly": This symptom may indicate orthostatic hypotension, a common side effect of some antipsychotics. While it is important to monitor, it is less urgent than the motor symptoms associated with extrapyramidal effects, which can significantly impact the client’s safety and well-being.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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