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 Glasgow coma scale (GCS) rating of 15 indicates that the client is able to obey commands.
B. Correct. A GCS rating of 15 indicates that the client is fully conscious and oriented to person, place, and time.
C. Incorrect. Opening eyes to sound is a response associated with the eye-opening component of the GCS score, but this response does not provide information about the client's orientation.
D. Incorrect. Withdrawing from pain is a response associated with the motor component of the GCS score, but this response does not provide information about the client's orientation.

A. "I'm sure you can find alternative remedies through an online support group." B. "We can review some information to help you select a safe alternative practitioner." C. "Feel free to try whatever therapies that fit within your personal belief system." D. "If there are therapies available to you, your provider will tell you about them."

Correct Answer is B

Explanation

A. Incorrect. Suggesting finding alternative remedies through an online support group may not provide accurate or safe information.
B. Correct. This response acknowledges the client's interest and offers to provide guidance in selecting a safe alternative practitioner. It's important to ensure that any alternative therapies are safe and evidence-based.
C. Incorrect. While it's important to respect the client's personal beliefs, the nurse should also ensure that the chosen therapies are safe and effective.
D. Incorrect. Waiting for the provider to suggest alternative therapies may delay the client's access to safe and effective treatments.

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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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