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 C
Explanation
A. While this may be a risk factor for some behaviors, it is not as strong a predictor of violence as a history of actual violent behavior.
B. Although statistics show higher rates of violence among males, it's not a specific predictor for individual behavior.
C. Previous violent behavior is the strongest predictor of future violence.
Understanding a client's history of violence is critical in assessing risk and planning interventions.
D. While certain types of delusions may increase risk, they are not as definitive in predicting violence as past violent behaviors.
Correct Answer is ["B","C","E","F"]
Explanation
A. While it's important to assess pedal pulses regularly, there is no indication in the scenario that the pedal pulses are abnormal or require immediate follow-up. The description mentions bilateral pedal pulses being present and intact throughout both days, suggesting no acute issues with peripheral circulation.
B. Crackles heard at the bases indicate possible pulmonary complications such as atelectasis or pneumonia, requiring further assessment and intervention.
C. A heart rate of 112/min indicates tachycardia, which could be a sign of pain, anxiety, or underlying cardiovascular issues. Further evaluation is needed to determine the cause.
D. The scenario states that the movement and sensation of the right foot are intact, with warm skin and no change in pigmentation. There are no signs of compromised neurovascular status in the right foot based on the provided information, so immediate follow-up for this finding is not necessary.
E. A respiratory rate of 28/min is elevated, suggesting respiratory distress or inadequate ventilation. Prompt assessment and intervention are necessary to address any respiratory issues.
F. A pulse oximetry reading of 88% on room air indicates hypoxemia, which requires immediate attention to ensure adequate oxygenation. Further assessment and intervention are needed to improve oxygen saturation levels.
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