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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?

A.

A residual of 65 mL 1 hr postprandial

B.

Sitting in high-Fowler's position during the feeding

C.

A history of gastroesophageal reflux disease

D.

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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Related Questions

Correct Answer is A

Explanation

A. Correct. A filter needle should be used to withdraw medication from an ampule to prevent drawing up any glass fragments into the syringe.
B. Using the same needle to draw up and inject the client is not recommended to prevent contamination.
C. Breaking the neck of the ampule toward the body is not a safe practice, as it can cause injury.
D. Ampules should be disposed of properly in a sharps container, not a regular trash can.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

Pyrexia, also known as fever, refers to an elevated body temperature that is above the normal range. The normal body temperature is typically around 37°C (98.6°F), and a temperature of 38.4°C (101.1°F) indicates a fever.

Alternative Choices:

1. "tachycardia" due to "heart rate of 92/min"

  • Incorrect. Tachycardia refers to an abnormally high heart rate, usually above 100 beats per minute (bpm) in adults. A heart rate of 92/min is within normal limits and does not qualify as tachycardia.

2. "hypertension" due to "blood pressure of 130/78 mm Hg"

  • Incorrect. Hypertension is defined as having a blood pressure reading consistently above 140/90 mm Hg. The reading of 130/78 mm Hg falls into the elevated category but does not reach the threshold for hypertension.

3. "respiratory distress" due to "respiratory rate of 18/min"

  • Incorrect. A respiratory rate of 18 breaths per minute is considered normal for adults, so this finding does not indicate respiratory distress.

4. "obesity" due to "current BMI of 29.9"

  • Partially correct. A BMI of 29.9 places the client in the "overweight" category, just below the threshold for obesity (BMI of 30 or higher). However, the presence of pyrexia is the more immediate clinical concern based on the provided vital signs.

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