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. A client receiving heparin for deep-vein thrombosis should not be discharged early.
B. Correct. This client is the most appropriate candidate for early discharge in anticipation of multiple client admissions. Vertebroplasty is a minimally invasive procedure that typically requires only a short hospital stay. The client is likely stable at 1 day post-procedure and can be discharged with appropriate follow-up care.
C. Incorrect. A client with COPD and a respiratory rate of 44/min needs immediate attention, not early discharge.
D. Incorrect. This client is stable for discharge, as sealed radiation implants typically do not require hospitalization after a certain point, assuming they are stable and able to manage their care at home. Discharging this client can help free up resources for incoming patients, provided they have appropriate support at home.

A. Client reports lower back pain and pinkish vaginal discharge. B. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. C. Cervical exam indicates 2 cm, 50% effaced, 0 station. D. CBC and urinalysis collected and sent to lab. E. FHR baseline 145, minimal variability.

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

Explanation

Client reports lower back pain and pinkish vaginal discharge.

Explanation: Lower back pain and pinkish discharge can indicate preterm labor, especially given the client’s history of a previous preterm birth.

Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.

Explanation: Frequent and strong contractions suggest that labor may be progressing, which is concerning at 33 weeks gestation and needs close monitoring.

FHR baseline 145, minimal variability.

Explanation: Minimal variability in the fetal heart rate (FHR) can be a sign of fetal distress or a lack of fetal well-being, warranting further evaluation.

Cervical exam indicates 2 cm, 50% effaced, 0 station.

Explanation: Cervical dilation and effacement at 33 weeks gestation indicate that labor is progressing. Given the client's history of preterm birth, this finding is concerning and requires intervention to try to prevent another preterm delivery.

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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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Naxlex Comprehensive Predictor Exams

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

Correct Answer is B

Explanation

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

Explanation

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