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 D

Explanation

Choice A rationale:

Diazepam (Valium) is not the correct choice in this situation. Diazepam is a sedative and muscle relaxant but would not address the respiratory depression caused by hydromorphone. The client's respiratory rate of 10/min indicates a potential opioid overdose, and the appropriate intervention is to administer naloxone to reverse the opioid effects.

Choice B rationale:

Acetaminophen (Tylenol) is not the correct choice in this scenario. Acetaminophen is a pain reliever and fever reducer but would not address the respiratory depression caused by hydromorphone. The priority is to address the respiratory depression promptly with naloxone.

Choice C rationale:

Ibuprofen (Advil) is not the correct choice in this situation. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation but is not appropriate for reversing opioid-induced respiratory depression. Naloxone is the drug of choice to reverse opioid overdose in this case.

Choice D rationale:

Naloxone (Narcan) is the correct choice. Naloxone is an opioid receptor antagonist used to reverse the effects of opioid overdose, including respiratory depression. Given the client's low respiratory rate, naloxone should be administered promptly to counteract the effects of hydromorphone. This is the most appropriate and potentially life-saving intervention for this client.

A. A nurse expresses concern that another shift works fewer holiday hours. B. A nurse has a personal difficulty with caring for clients who have HIV. C. A nurse experiences insulting comments directed at them by another nurse. D. A nurse submits a complaint about another department's handoff reporting.

Correct Answer is C

Explanation

Choice A rationale:

Expressing concern about another shift's holiday hours does not necessarily involve interpersonal conflict. It may reflect dissatisfaction but doesn't involve direct conflict between individuals.

Choice B rationale:

A personal difficulty with caring for clients who have HIV could be a challenge for the nurse, but it's not an example of interpersonal conflict. It represents a personal struggle rather than a conflict with another individual.

Choice C rationale:

Insulting comments directed at a nurse by another nurse represent interpersonal conflict. Such behavior involves a direct clash of personalities and can create a hostile work environment, affecting the nurse's well-being and job performance. Addressing this type of conflict is crucial for maintaining a positive work atmosphere.

Choice D rationale:

Submitting a complaint about another department's handoff reporting might indicate dissatisfaction or concerns about workflow, but it's not necessarily an interpersonal conflict. It could be a communication issue or a difference in professional opinion rather than a direct clash between individuals.

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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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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?