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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B: Speak in a normal voice at a natural pace.
Choice A rationale: Directing statements to the interpreter is inappropriate because it can make the client feel excluded from the conversation. The focus of communication should be on the client, and the interpreter is present only to facilitate understanding between the nurse and the client. Direct eye contact and addressing the client directly is important for establishing rapport and trust.
Choice B rationale: Speaking in a normal voice at a natural pace is crucial when working with an interpreter to ensure accurate translation and comprehension. It provides the interpreter with enough time to accurately convey the message while maintaining a conversational flow. Speaking too fast or in an unnatural tone can create confusion and lead to misinterpretation, ultimately affecting the quality of care provided to the client.
Choice C rationale: Using gestures while speaking with the client may not be helpful when working with an interpreter. Gestures may be culturally specific and can lead to misunderstandings or misinterpretations. Furthermore, the interpreter may not be able to accurately convey the intended message through gestures, leading to communication errors.
Choice D rationale: Pausing in the middle of sentences is not recommended when working with an interpreter. This practice can disrupt the flow of the conversation, confuse the interpreter, and lead to incomplete translations. It is essential to speak in complete sentences and provide pauses between sentences to enable the interpreter to accurately translate the information to the client.
Correct Answer is D,C,B,A
Explanation
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