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) Ensuring that the client's family supports the provider's decision for surgery is important, but it is secondary to confirming that the healthcare surrogate is informed about the risks and benefits. The family’s emotional support is valuable, but informed consent is paramount.
B) Determining if the client's health care surrogate is aware of the risks and benefits of the procedure is crucial. Since the client is in a coma and unable to provide informed consent, the surrogate must be fully informed to make appropriate decisions regarding the client's care. This ensures that the rights and wishes of the client are upheld.
C) Sending the unsigned informed consent form to the facility's risk manager may be a procedural step in some situations, but it does not directly address the immediate need for informed consent or ensure that the healthcare surrogate understands the implications of the procedure. This action can be part of post-decision documentation but is not the first priority.
D) Determining if the procedure is medically necessary is important; however, the immediate concern is ensuring that informed consent is obtained from the health care surrogate. Understanding the necessity of the procedure can be part of the discussion with the surrogate but does not replace the need for informed consent.
Correct Answer is C
Explanation
A. Obtain a trough level 30 min after the medication infusion: Trough levels should be drawn just before the next dose, not 30 minutes after the infusion. This timing ensures accurate measurement of the drug’s lowest concentration in the bloodstream.
B. Inject 1% lidocaine prior to each dose: While lidocaine may help reduce discomfort at the injection site, it is not a standard practice for all patients receiving vancomycin and does not address the risk of systemic adverse reactions.
C. Give the dose over 60 min: Administering vancomycin over a period of at least 60 minutes is essential to minimize the risk of infusion-related reactions, such as "red man syndrome," which can occur if the drug is infused too quickly.
D. Administer the medication undiluted: Vancomycin should always be diluted according to guidelines before administration to reduce the risk of irritation to the veins and potential adverse reactions. Administering undiluted increases the risk of complications.
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