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 residual of 65 mL 1 hr postprandial.
A history of gastroesophageal reflux disease.
Receiving a high-osmolarity formula.
Sitting in high-Fowler's position during the feeding.
The Correct Answer is B
A. This amount of residual is generally considered safe; guidelines often cite higher residuals (e.g., >100 mL) as concerning.
B. Clients with a history of gastroesophageal reflux disease (GERD) are at increased risk for aspiration, particularly when lying flat, because the lower esophageal sphincter may not function properly, allowing stomach contents to move back into the esophagus.
C. While high-osmolarity formulas can contribute to diarrhea, they are not directly linked to an increased risk of aspiration.
D. Sitting in a high-Fowler’s position (semi-upright) during feedings is actually recommended to reduce the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: It's not the nurse's role to provide detailed information about the benefits of surgery on the informed consent form; this should be done by the provider.
B: Informing the client about their condition is primarily the provider's responsibility before obtaining consent.
C: The nurse should not be the one to explain the procedure; this is the provider's responsibility. The nurse ensures the client understands after the provider's explanation.
D: Confirming the client's signature is authentic is a crucial step for the nurse to ensure that the consent is valid and the client has indeed agreed to the procedure.
Correct Answer is B
Explanation
A. This amount of residual is generally considered safe; guidelines often cite higher residuals (e.g., >100 mL) as concerning.
B. Clients with a history of gastroesophageal reflux disease (GERD) are at increased risk for aspiration, particularly when lying flat, because the lower esophageal sphincter may not function properly, allowing stomach contents to move back into the esophagus.
C. While high-osmolarity formulas can contribute to diarrhea, they are not directly linked to an increased risk of aspiration.
D. Sitting in a high-Fowler’s position (semi-upright) during feedings is actually recommended to reduce the risk of aspiration.
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