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 D
Explanation
A. Incorrect. This client is immobile but not at immediate risk from fire.
B. Incorrect. While a bedridden client wearing a hearing aid requires assistance, they are not in immediate danger like a client in traction.
C. Incorrect. A client using a wheelchair and being confused requires assistance, but the urgency is not as high as with a client in traction.
D. Correct. Oxygen is a highly combustible gas, and any spark or open flame near an oxygen source can ignite a fire. Therefore, clients receiving oxygen are at the highest risk during a fire.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}
Explanation
A. Administer oxytocin. (This is unanticipated as the client is experiencing contractions, and oxytocin might not be needed at this point.)
D. Limit fluid intake to 3,000 mL/day. (Fluid restriction might not be necessary based on the provided notes.)
F. Place client in supine position. (The supine position is generally avoided during pregnancy due to potential compression of the vena cava.)
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