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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Enhanced mood: While a better mood can be beneficial for overall well-being, it is not a direct measure of donepezil's effectiveness, which primarily targets cognitive function.
B. Increased food intake: Improved appetite may occur, but it is not a primary indication of the effectiveness of donepezil, which focuses on cognitive enhancement.
C. Can perform ADLs independently: Although increased independence in activities of daily living (ADLs) is positive, it may not solely be attributed to donepezil, as various factors affect a person's ability to perform ADLs.
D. Improved short-term memory: This is the most direct indicator of donepezil's effectiveness, as the medication is designed to improve cognitive function, particularly in individuals with Alzheimer’s disease or other types of dementia. Enhanced short-term memory directly reflects the intended therapeutic effect of the medication.
Correct Answer is B
Explanation
A. The client is observed mumbling quietly while alone in the day room: This behavior may be related to the client’s schizophrenia and is not necessarily indicative of an adverse effect from the antipsychotic medication. It is common for individuals with schizophrenia to exhibit such behaviors, which may not require reporting.
B. The client is observed displaying a shuffling gait while walking in the hall: A shuffling gait can indicate extrapyramidal symptoms, such as Parkinsonism, which are potential adverse effects of antipsychotic medications. This observation requires immediate reporting to the provider for further assessment and potential adjustment of the medication.
C. The client states, "Being in the sun seems to really hurt my eyes": Photosensitivity can occur with some medications, including antipsychotics, but it is not as urgent an issue as extrapyramidal symptoms. While this should be documented and addressed, it does not necessarily require immediate intervention.
D. The client states, "I feel light-headed when I stand up quickly": This symptom may indicate orthostatic hypotension, a common side effect of some antipsychotics. While it is important to monitor, it is less urgent than the motor symptoms associated with extrapyramidal effects, which can significantly impact the client’s safety and well-being.
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