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?

A residual of 65 mL 1 hr postprandial

Sitting in high-Fowler's position during the feeding

A history of gastroesophageal reflux disease

Receiving a high-osmolarity formula

Answer and Explanation

The Correct Answer is C

A. Incorrect. A residual of 65 mL may indicate delayed gastric emptying, but it alone does not directly correlate with an increased risk of aspiration unless it leads to significant overdistension or the client is unable to tolerate further feedings.

B. Incorrect. Sitting in high Fowler's position during feeding is actually a preventive measure against aspiration.

C. Correct. his factor increases the risk for aspiration. Clients with gastroesophageal reflux disease (GERD) are more prone to refluxing contents from the stomach into the esophagus, which can lead to aspiration, especially during or after feedings.

D. Incorrect. The osmolarity of the formula might affect tolerance but is not directly related to aspiration risk.

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Correct Answer is B

Explanation

A. Incorrect. Encouraging clients to establish a timeline for grieving might not be appropriate or helpful, as grief processes are individual and non-linear.
B. Correct. Coping with changes in family dynamics is a relevant topic for a support group of this nature, as suicide often brings significant family changes.
C. Incorrect. Focusing on preventing suicide is not the primary goal of this support group; coping and healing are more appropriate.
D. Incorrect. Allowing clients to share negative aspects of their relationship can promote emotional healing and understanding, which is essential in this context.

A. "I can go jogging after 2 weeks." B. "I should bend at the waist when putting on my shoes." C. "I can lift objects that are less than 10 pounds." D. "I can resume activities, such as sewing."

Correct Answer is C

Explanation

A.Jogging or any form of vigorous exercise, especially high-impact activities, should generally be avoided for at least 4–6 weeks after retinal surgery. This is because high-impact activities can increase intraocular pressure and potentially disrupt the healing retina. Jogging involves bouncing or jolting movements, which could adversely affect the repair.

B. Bending at the waist places increased pressure on the eye and can disrupt the healing process after retinal surgery. This action increases intraocular pressure and is typically discouraged postoperatively.

C. Light lifting, such as lifting objects under 10 pounds, is typically allowed after several weeks of recovery, once the initial healing has occurred and the client is no longer at risk for increasing intraocular pressure or straining the surgical site.

D. While sewing itself is a low-impact activity, the act of sewing typically involves bending over or placing the head below the waist, which could still increase intraocular pressure. Early postoperative instructions often caution against activities that involve bending or straining the eyes, such as sewing, reading, or watching TV for extended periods.

D. Correct. After surgical repair of a detached retina, clients should avoid activities that might increase intraocular pressure, like heavy lifting or bending at the waist. Activities that do not strain the eye, like sewing, can typically be resumed earlier.

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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

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