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) Monitor the client's aPTT levels: While monitoring the activated partial thromboplastin time (aPTT) is important for managing heparin therapy, it is not the immediate priority after a significant medication error. The potential for bleeding due to the overdose is the most critical concern.
B) Check the client for indications of bleeding: This is the first and most crucial action. Assessing the client for signs of bleeding (such as bruising, hematuria, or bleeding gums) is essential to ensure their safety following an overdose of heparin, which can lead to life-threatening complications.
C) Complete an incident report: Documenting the medication error is important for institutional accountability and quality improvement. However, this action should occur after immediate patient safety is addressed.
D) Notify the risk manager: While this is an important step in the reporting process, it should be done after ensuring the client’s safety and taking appropriate actions to address any potential adverse effects of the medication error.
Correct Answer is C
Explanation
A) Taking your temperature 1 hour after getting out of bed is not appropriate for the basal body temperature method. For accurate tracking, temperature should be taken immediately upon waking, before any activity or movement that could affect the reading.
B) Taking your temperature every night before going to bed does not align with the basal body temperature method. This method requires consistent morning measurements to track ovulation accurately, as body temperature can fluctuate throughout the day.
C) Taking your temperature immediately after waking and before getting out of bed is the correct instruction. This ensures the reading reflects the body's resting temperature, which can help identify the slight increase that occurs after ovulation, aiding in family planning efforts.
D) Taking your temperature within 30 minutes after your first morning void is not suitable for this method. The ideal time is right upon waking, and any activity, including using the bathroom, can alter body temperature and lead to inaccurate readings.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.