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?

Sitting in high-Fowler's position during the feeding.

A history of gastroesophageal reflux disease.

A residual of 65 mL 1 hr postprandial.

Receiving a high-osmolarity formula.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.

Choice B rationale:

A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.

Choice C rationale:

A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.

Choice D rationale:

Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.

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Correct Answer is A

Explanation

Choice A rationale:

"Since I retired, I have entered many gardening competitions." This statement indicates compensation as a defense mechanism. Compensation involves emphasizing personal strengths in one area to shift focus from failure or weakness in another. In this case, the client is finding fulfillment and recognition in gardening competitions after retiring, compensating for the loss of work-related identity.

Choice B rationale:

Expressing relief about retirement due to negative work experiences doesn’t necessarily indicate compensation. It could be a coping mechanism, but it doesn't align with the compensation defense mechanism, which involves overachieving in one area to compensate for deficiencies in another.

Choice C rationale:

Choice D rationale:

Journaling about career accomplishments after layoffs indicates sublimation, not compensation. Sublimation is a defense mechanism where unacceptable impulses or behaviors are transformed into socially acceptable actions or pursuits, like channeling frustration or disappointment into creative or productive activities such as journaling.

A. Placental abruption. B. Cervical insufficiency. C. Seizures. D. Hypoglycemia. E. Heart failure.

Correct Answer is ["A","C"]

Explanation

The correct answers are Choices A and C.

Choice A rationale: Severe hypertension in pregnancy disrupts placental perfusion and vascular integrity, increasing risk of placental abruption due to premature separation and hemorrhage, threatening both maternal and fetal outcomes.

Choice B rationale: Cervical insufficiency is linked to structural weakness or trauma, not hypertension; it typically presents with painless dilation and is unrelated to elevated blood pressure or vascular compromise.

Choice C rationale: Hypertensive encephalopathy and preeclampsia can progress to eclampsia, marked by seizures. Elevated BP increases cerebral edema and excitability, triggering convulsions if unmanaged.

Choice D rationale: Hypoglycemia is not a direct consequence of hypertension; it’s more associated with insulin dysregulation, poor intake, or medication effects, not elevated blood pressure.

Choice E rationale: Heart failure may occur in chronic hypertension but is less acute than seizure or abruption risk in this context. No signs of fluid overload or cardiac decompensation are present in the vitals.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the coping strategies of a client who has recently retired.Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?

Correct Answer is A

Explanation

Correct Answer is ["A","C"]

Explanation

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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?