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 A
A. Correct. A large residual volume (greater than 50-100 mL) after feeding can indicate delayed gastric emptying and increases the risk of aspiration.
B. Incorrect. Sitting in high Fowler's position during feeding is actually a preventive measure against aspiration.
C. Incorrect. A history of gastroesophageal reflux disease increases the risk of reflux but does not directly correlate with aspiration risk.
D. Incorrect. The osmolarity of the formula might affect tolerance but is not directly related to aspiration risk.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Constipation is a potential side effect of morphine, but it is not the priority concern in this scenario.
B. Euphoria is a potential side effect of morphine but is not as immediately concerning as bradypnea.
C. Correct. Bradypnea (slow breathing) is a potential adverse effect of morphine and can lead to respiratory depression, which is a serious concern.
D. Sedation is an expected side effect of morphine, but the priority concern is the possibility of respiratory depression.
Correct Answer is D
Explanation
A. Incorrect. Open discussion is important to address the changes and challenges resulting from the stroke. Avoiding discussions might hinder effective communication and problem-solving.
B. Incorrect. Socialization with extended relatives can provide valuable support during this transition and should not be decreased without reason.
C. Incorrect. Authoritative communication might not be suitable for all family dynamics.
Effective communication should be respectful and tailored to the specific needs and preferences of the individuals involved.
D. Correct. Implementing firm but flexible boundaries allows for a healthy balance between support and maintaining the client's independence and autonomy.
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