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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Ensuring the device inspection sticker is current is important but not the first action to take when there's a potential safety issue.
B. Incorrect. Reporting the defect is important, but immediate action to ensure client safety should come first.
C. Correct. The nurse's first priority should be ensuring client safety. Removing the device from the room prevents any potential harm from using the device with a frayed cord.
D. Incorrect. Initiating a requisition for a replacement is important, but immediate action to ensure safety is a higher priority.
Correct Answer is ["255"]
Explanation
Step 1: Calculate half the total volume. The total volume is 4,080 mL. So, half the total volume is 4,080 mL ÷ 2 = 2,040 mL.
Step 2: Calculate the rate to administer half the total volume in the first 8 hours. So, the rate is 2,040 mL ÷ 8 hr = 255 mL/hr.
Therefore, the nurse should set the IV infusion pump to deliver 255 mL/hr to administer half the total volume in the first 8 hr.
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