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 D

Explanation

A) Administer 0.9% sodium chloride IV: While fluid replacement is important in managing a thyroid storm, it is not the immediate priority compared to monitoring critical symptoms.

B) Provide a cooling blanket: Hyperthermia is a concern in a thyroid storm, and cooling measures are necessary, but they are secondary to addressing the cardiovascular effects.

C) Obtain the client's blood glucose: Monitoring blood glucose is important, especially in a hypermetabolic state, but it is not the most immediate concern in the context of a thyroid storm.

D) Monitor the client's cardiac rhythm: This is the priority action. Thyroid storm can cause significant cardiovascular complications, including tachycardia and arrhythmias. Continuous monitoring of the cardiac rhythm is essential to detect any life-threatening changes and to provide prompt intervention if necessary.

A. Touch the client gently to announce presence. B. Ensure there is high-wattage lighting in the client's room. C. Keep objects in the client's room in the same place. D. Approach the client from the side. E. Allow extra time for the client to perform tasks.

Correct Answer is ["A","C","E"]

Explanation

A. Touch the client gently to announce presence: Gently touching the client’s arm or shoulder can help orient them to your presence and is a considerate way to communicate, especially when they have vision loss.

B. Ensure there is high-wattage lighting in the client's room: While good lighting is important, high-wattage lighting can create glare, which may be uncomfortable or disorienting for clients with vision loss. Instead, softer, diffused lighting is often more effective.

C. Keep objects in the client's room in the same place: Maintaining a consistent layout in the client’s environment helps them navigate safely and independently. It minimizes confusion and reduces the risk of accidents.

D. Approach the client from the side: Approaching from the front is typically better for clients with vision loss, as it allows them to see you (if they have some vision) and helps them feel less startled.

E. Allow extra time for the client to perform tasks: Providing extra time respects the client's pace and fosters independence. It acknowledges the challenges they may face due to vision loss, allowing them to complete tasks without feeling rushed.

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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

A nurse is caring for a client who has Graves' disease and is experiencing a thyroid storm. Which of the following actions is the nurse's priority?

Correct Answer is D

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