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 D

Explanation

Choice A rationale:

A sore throat is a common and expected finding after a tonsillectomy due to irritation from the procedure. While it can cause discomfort, it is not a priority concern unless it worsens significantly or is accompanied by other symptoms indicating complications such as bleeding or infection.

Choice B rationale:

Frequent swallowing is expected after a tonsillectomy due to the presence of throat pain and swelling. It is not a priority concern unless it is excessive or accompanied by signs of bleeding, such as vomiting blood.

Choice C rationale:

Blood-tinged mucus is a common finding in the immediate postoperative period after a tonsillectomy. It is expected due to the healing process and is not a cause for concern unless it becomes profuse or is accompanied by active bleeding.

Choice D rationale:

Dark brown emesis is a concerning finding after a tonsillectomy. It could indicate bleeding from the surgical site or another gastrointestinal issue. Dark brown emesis suggests that the blood has been partially digested, indicating that the bleeding might be higher up in the gastrointestinal tract. This finding requires immediate medical attention as it could lead to significant blood loss and complications if not addressed promptly.

A. Initiate airborne precautions. B. Monitor for the development of Koplik spots. C. Administer aspirin to the client. D. Isolate the client from staff who are pregnant.

Correct Answer is D

Explanation

A. Incorrect. Rubella is not transmitted via airborne routes. Droplet precautions are typically not required for rubella.

B. Incorrect. Koplik spots are a characteristic of measles, not rubella.

C. Incorrect. Aspirin administration is contraindicated in adolescents with viral infections due to the risk of Reye's syndrome.

D. Correct. Rubella is a teratogenic virus that can cause birth defects in pregnant women who are exposed to the virus. Isolation from pregnant staff members is important to prevent potential transmission.

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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

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