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 A,B,C,D
Explanation
To delegate tasks to assistive personnel (APs) effectively, the nurse should follow this sequence:
- A. Review the skill level and qualifications of each AP.
- B. Communicate appropriate tasks to the APs with specific expectations.
- C. Monitor progress of task completion with each AP.
- D. Evaluate the APs' performance of each task.
This order ensures that the nurse first assesses the abilities of the APs, then clearly communicates tasks, monitors their progress, and finally evaluates their performance.
Correct Answer is D
Explanation
A. Premature Infant Pain Profile (PIPP): This scale is specifically designed for assessing pain in preterm infants and may not be suitable for a newborn delivered at 38 weeks of gestation.
B. FACES pain rating scale: This scale is typically used for older children who can understand and relate to facial expressions, making it inappropriate for assessing pain in newborns.
C. Visual analog scale (VAS): This scale is also not suitable for newborns, as it requires the ability to understand and interpret a continuous scale, which newborns cannot do.
D. Neonatal Infant Pain Scale (NIPS): This is the most appropriate choice for assessing pain in a newborn. It evaluates indicators such as facial expression, cry, breathing patterns, and extremity movement, making it suitable for this age group and context.
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