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 B

Explanation

A) Increase the suction pressure as tolerated: Increasing the suction pressure is not recommended as it can cause damage to the gastric mucosa and lead to complications such as bleeding or ulceration. The suction pressure should be set according to the healthcare provider’s orders and the manufacturer’s guidelines.

B) Flush the tube with 0.9% sodium chloride: Flushing the NG tube with 0.9% sodium chloride is an appropriate action to maintain patency and prevent clogging. This helps ensure that the tube remains functional for effective suction and reduces the risk of complications such as infection or blockage.

C) Replace the NG tube every 24 hr: Replacing the NG tube every 24 hours is unnecessary and can cause discomfort and trauma to the client. NG tubes are typically replaced only when they become clogged, dislodged, or as per the healthcare provider’s orders.

D) Position the client supine in bed: Positioning the client supine in bed is not recommended as it increases the risk of aspiration. The client should be positioned with the head of the bed elevated to reduce the risk of aspiration and promote proper drainage through the NG tube.

A. Bradypnea B. Jugular vein distention C. Weight gain D. Frothy, pink sputum

Correct Answer is D

Explanation

A. Bradypnea: This refers to a slower than normal respiratory rate, which is not a typical manifestation of pulmonary congestion. In fact, pulmonary congestion often leads to tachypnea (increased respiratory rate).

B. Jugular vein distention: This is more indicative of right-sided heart failure or fluid overload rather than left-sided heart failure, where the primary issue is related to pulmonary congestion.

C. Weight gain: While weight gain can occur due to fluid retention in heart failure, it is not specific to pulmonary congestion and can be seen in both left-sided and right-sided heart failure.

D. Frothy, pink sputum: This is a classic manifestation of pulmonary congestion and indicates the presence of fluid in the lungs, often seen in left-sided heart failure. The pink color is due to the presence of blood, which may leak into the alveoli due to increased pressure. This finding is critical and should be closely monitored.

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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

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