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.

Answer and Explanation

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.

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Correct Answer is ["B","C","E","F"]

Explanation

A. Douching is not recommended during pregnancy as it can disrupt the natural balance of vaginal flora and increase the risk of infection.
B. Loose-fitting clothing allows for better air circulation and can help prevent discomfort and irritation, especially with increased sweating and vaginal discharge during pregnancy.

C. Flat or low-heeled shoes provide better support and stability, reducing the strain on the back and pelvis, which can alleviate backaches common during pregnancy.
D. Hot showers can exacerbate itching, especially if the skin is already irritated.

Lukewarm or cool showers are preferable for relieving itching.

E. Fried foods can contribute to heartburn and indigestion, which are common during pregnancy due to hormonal changes and increased pressure on the stomach from the growing uterus.
F. An abdominal support belt can help alleviate backaches by providing additional support to the abdomen and reducing strain on the back muscles.
G. Eating frequent, smaller meals throughout the day is recommended during pregnancy to help manage heartburn, prevent overeating, and maintain stable blood sugar levels.

A. "That can't be true. The only voices in this room are yours and mine." B. "You shouldn't be afraid when you think the voices are telling you to hurt yourself." C. "I understand the voices are frightening you, but I do not hear any voices." D. "Do you recognize the voices as belonging to anyone you know?"

Correct Answer is C

Explanation

A: This response invalidates the client's experience and may cause them to feel misunderstood or alienated.
B: This response does not address the seriousness of the client's statement and dismisses their fear.
C: This is an appropriate response because it acknowledges the client's experience without agreeing with the delusion, helping to maintain a grasp on reality.
D: While this question could be useful during a more in-depth conversation, it does not address the immediate safety concern and may not help deescalate the situation.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in an outpatient clinic is caring for a client. Exhibits Which of the following statements should the nurse include in the client's teaching? Select all that apply.

Correct Answer is ["B","C","E","F"]

Explanation

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Correct Answer is C

Explanation

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