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

Answer is: a. "The estimated blood loss was 250 milliliters."

Explanation: Including the estimated blood loss during the procedure in the hand-off report is relevant information that impacts the patient's care and helps the receiving nurse assess the patient's condition and monitor for complications.

Choice b. is wrong because the client has been transferred to the PACU, it is implied that the intubation has been removed. The focus should be on the patient's current condition and any potential complications related to the procedure.

Choice c. is wrong because the client's role as a member of the board of directors does not directly affect their medical care. Nurses should maintain patient confidentiality and only discuss relevant information regarding the patient's health status.

Choice d. is wrong because the number of sponges used during the procedure is not essential information to include in the hand-off report. The focus should be on the patient's current condition and any potential complications.

A. "Your baby will be given 2 ounces of water to drink prior to the test." B. "This test will be repeated when your baby is 2 months old." C. "This test should be performed after your baby is 24 hours old." D. "A nurse will draw blood from your baby's inner elbow." .

Correct Answer is C

Explanation

Choice A rationale:

Administering 2 ounces of water to the newborn prior to the test is not a standard practice for newborn genetic screening. Newborns are typically screened for genetic disorders through a blood test, not by giving them water.

Choice B rationale:

This statement is incorrect. Newborn genetic screening is usually performed shortly after birth, not at 2 months old. Early screening allows for the early detection of certain genetic disorders, enabling timely interventions if needed.

Choice D rationale:

Drawing blood from the newborn's inner elbow is not specific guidance related to newborn genetic screening. Blood can be drawn from various sites, and healthcare providers choose the most appropriate site based on the newborn's condition and the required tests.

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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?