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
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Explanation
Yellowing of the eyes could indicate hepatotoxicity, a serious adverse effect associated with some of the anti-tuberculosis medications, particularly rifampin.
Blurred vision could be a sign of optic neuritis, a rare but serious adverse effect associated with ethambutol.
Abdominal pain could indicate hepatitis or hepatotoxicity, which are potential adverse effects of anti-tuberculosis medications like isoniazid and rifampin.
Increased bruising could indicate thrombocytopenia, a serious adverse effect associated with some anti-tuberculosis medications, particularly rifampin.
Increased bleeding tendency could also indicate thrombocytopenia or other hematologic abnormalities.
Red/orange tint to urine could indicate rifampin-induced discoloration of bodily fluids, which is not harmful but can be alarming to patients.
Darkening of urine could also be a result of rifampin-induced discoloration. It's important to differentiate between this harmless side effect and hematuria, which could indicate a more serious issue.
Correct Answer is C
Explanation
A. Transdermal nicotine patches should be applied immediately after removal from the protective pouch, but waiting for up to 1 hour is acceptable according to most manufacturers' instructions.
B. Shaving hairy areas of skin is not necessary prior to applying a transdermal nicotine patch and may cause skin irritation.
C. Wearing gloves during the application of the transdermal nicotine patch helps to prevent nicotine absorption through the nurse's skin and reduces the risk of accidental exposure.
D. The nurse should properly dispose of the previous patch according to facility protocols rather than placing it in a tissue, as used nicotine patches can still contain active medication and pose a risk of exposure.
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