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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Playing with an imaginary friend: While imaginative play does begin to develop in toddlers, having an imaginary friend is more typical in older preschool-aged children, around 3 to 4 years old. Therefore, this activity may not be expected in a 30-month-old child.
B) Playing with a large plastic truck: At 30 months old, children are typically engaged in parallel play and are interested in toys that promote gross motor skills and imaginative play. Playing with a large plastic truck is developmentally appropriate, as children at this age enjoy manipulating vehicles and may engage in simple pretend play related to driving or racing.
C) Playing with dress-up clothes: Although some children may enjoy dress-up, this activity tends to be more prominent in slightly older toddlers and preschoolers. A 30-month-old may show interest in dressing up but may not engage in it as frequently or with as much understanding of role play as older children.
D) Playing with a jump rope: Jump rope activities require a level of coordination and motor skills that are typically beyond what a 30-month-old child can achieve. At this age, children are still developing basic motor skills and would not yet be proficient in using a jump rope effectively.
Correct Answer is A
Explanation
A. Faint pedal pulse of left leg: A faint pedal pulse indicates poor circulation and is a clear sign of altered tissue perfusion. It suggests that the blood flow to the affected extremity may be compromised, warranting immediate assessment and intervention.
B. Pain with movement of the left great toe: While pain may indicate an issue, it does not specifically indicate altered tissue perfusion. Pain can result from various causes, including injury or inflammation, but it is not a direct measure of blood flow.
C. Purulent drainage at the pin site: Purulent drainage suggests infection rather than altered perfusion. While infections can affect tissue health, this finding does not directly indicate compromised blood flow to the extremity.
D. Warm skin temperature distal to pin site: Warm skin typically suggests adequate perfusion, as warmth can indicate good blood flow. In contrast, coolness or coldness would be a more concerning sign of altered perfusion.
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