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 C

Explanation

Choice A rationale:

Amputation, although a significant medical history, is not a contraindication to becoming a living kidney donor. The presence of an amputation does not directly impact the person's ability to donate a kidney to their parent.

Choice B rationale:

Primary glaucoma, a condition affecting the eyes, is also not a contraindication to kidney donation. While eye conditions can affect overall health, they do not specifically prevent an individual from donating a kidney if they are otherwise healthy.

Choice C rationale:

Hypertension (high blood pressure) is a contraindication to kidney donation. Individuals with hypertension are at a higher risk of developing kidney disease themselves. Additionally, donating a kidney could exacerbate their condition, potentially leading to further complications. Therefore, this is the correct choice.

Choice D rationale:

Osteoarthritis, a condition affecting the joints, is not a contraindication to kidney donation. Joint problems do not directly impact kidney function or the ability to donate a kidney.

A. Mix the medication with the client's food items. B. Speak in a neutral tone when addressing the client. C. Limit the client's opportunities to socialize with others. D. Rotate staff members caring for the client.

Correct Answer is B

Explanation

B) Speak in a neutral tone when addressing the client.

When creating a plan of care for a client with paranoid personality disorder who refuses to take their medication, it's essential to approach the client in a way that fosters trust and reduces anxiety. Speaking in a neutral, non-confrontational, and non-threatening tone can help build rapport and facilitate communication with the client.

The other options are not appropriate interventions:

A) Mixing medication with the client's food without their consent can be seen as a breach of trust and may worsen the client's paranoia.

C) Limiting the client's opportunities to socialize with others can lead to increased isolation and potentially exacerbate the client's paranoid tendencies.

D) Rotating staff members caring for the client may also contribute to feelings of mistrust and may not be conducive to establishing a therapeutic nurse-client relationship. Consistency in care can be more helpful for individuals with paranoid personality disorder.

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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 is caring for a client who has end-stage kidney disease.The client's adult child asks the nurse about becoming a living kidney donor for their parent.Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?

Correct Answer is C

Explanation

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Correct Answer is B

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?