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
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 D
Explanation
A. Incorrect. Polyhydramnios (excessive amniotic fluid) is not typically associated with placenta previa. It can be associated with conditions like fetal abnormalities or maternal diabetes.
B. Incorrect. Uterine tenderness might be present in conditions like uterine contractions, but it is not a primary finding in placenta previa.
C. Incorrect. Nausea is a common pregnancy symptom and is not directly related to placenta previa.
D. Correct. Spotting or painless vaginal bleeding is a hallmark sign of placenta previa, which occurs when the placenta covers part or all of the cervix. It can be life-threatening if severe bleeding occurs.
Correct Answer is C
Explanation
A. This is a stimulant laxative that works by increasing the movement of the intestines, helping the stool to come out. However, given the client's third-degree perineal laceration, a rectal suppository might cause discomfort and potentially disrupt the healing process.
B. Incorrect. Loperamide is an antidiarrheal medication and is not appropriate for constipation relief.
C. This is an osmotic laxative that works by drawing water into the intestines, which helps to soften the stool and stimulate bowel movements. It is taken orally and would not interfere with the healing of the perineal laceration.
D. Incorrect. Famotidine is an H2 blocker used to reduce stomach acid and is not indicated for constipation relief.
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