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 ["A","C","E"]

Explanation

A. Urine culture: This will help identify the presence of any urinary tract infection (UTI) causing discomfort and burning during urination.
B. Ibuprofen 600 mg every 6 hr for mild to moderate pain: While ibuprofen can help with pain relief, it does not address the potential underlying urinary tract infection, so it's important to address the infection first.
C. Obtain provider prescription for phenazopyridine: Phenazopyridine is a urinary analgesic that can provide relief from the pain and discomfort associated with UTIs.
D. Vaginal culture: The client's symptoms are related to discomfort and burning upon urination, suggesting a urinary tract issue rather than a vaginal issue. Therefore, a vaginal culture may not be relevant in this context.
E. Obtain provider prescription for antibiotics: If a urinary tract infection is suspected based on the client's symptoms and urine culture results, antibiotics may be needed to treat the infection.

A. Measure gastric residual volumes every 4 hr. B. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication. C. Maintain the head of the bed at a 20° angle. D. Advance the rate of the feeding every 2 hr.

Correct Answer is A

Explanation

A. Correct. Measuring gastric residual volumes every 4 hours is important to assess gastric emptying and to determine if the client can tolerate the feedings. If residuals are high, it may indicate delayed gastric emptying and the need to adjust the feeding rate.

B. Incorrect. While flushing the NG tube before and after medications is important to maintain patency, it is typically done with sterile water, not sodium chloride, unless otherwise specified by a protocol. Therefore, this statement may not be fully accurate.

C. Incorrect. The head of the bed should be elevated to a 30-45° angle to help prevent aspiration during enteral feedings.

D. Incorrect. The rate of the feeding should be advanced gradually to prevent overloading the client's gastrointestinal tract. This does not involve advancing the rate every 2 hours.

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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

Correct Answer is ["A","C","E"]

Explanation

A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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