A nurse is providing care to a group of patients in an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?

A patient with a colostomy.

A patient with an ileostomy.

A patient receiving enteral feedings through an NG tube.

A patient who has a chest tube following a motor vehicle crash.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A colostomy is a surgical procedure that creates an opening in the colon (large intestine) to divert stool through the abdomen. While a colostomy can affect bowel function, it does not directly increase the risk of aspiration. This is because the colon is located further down the digestive tract and does not directly involve the airway.

Choice B rationale:

An ileostomy is a surgical procedure that creates an opening in the ileum (small intestine) to divert stool through the abdomen. Similar to a colostomy, an ileostomy does not directly increase the risk of aspiration because the ileum is also located further down the digestive tract and does not involve the airway.

Choice C rationale:

Enteral feedings, also known as tube feedings, involve delivering nutrients directly into the stomach or small intestine through a tube. Patients receiving enteral feedings through a nasogastric (NG) tube are at a significantly higher risk of aspiration for several reasons:

Impaired swallowing mechanisms: Many patients who require enteral feedings have impaired swallowing mechanisms, which can increase the risk of food or liquid entering the airway instead of the esophagus.

Tube placement: The NG tube itself can potentially irritate the esophagus or interfere with the normal closure of the upper esophageal sphincter, which can increase the risk of reflux and aspiration.

Feeding formula: Enteral feeding formulas are often thin and liquid-like, which can make them easier to aspirate than thicker liquids or solid foods.

Positioning: Patients receiving enteral feedings are often in a reclined position, which can make it easier for fluids to travel back up the esophagus and into the airway.

Choice D rationale:

A chest tube is a drainage tube inserted into the chest cavity to remove air or fluid. While a chest tube can affect respiratory function, it does not directly increase the risk of aspiration. This is because the chest tube drains fluid from the pleural space, which surrounds the lungs, and does not directly involve the airway or digestive tract.

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Correct Answer is A

Explanation

Choice A rationale:

It is crucial for the nurse to prioritize patient safety and adhere to professional guidelines when encountering a potential diversion of controlled substances. Informing the charge nurse is the most appropriate initial action for several reasons:

Chain of Command: The charge nurse holds a supervisory position and is responsible for addressing issues within the unit, including concerns about medication diversion. Reporting suspicions to the charge nurse ensures adherence to the established chain of command and facilitates a prompt, organized response.

Confidentiality and Objectivity: The charge nurse is trained to handle sensitive situations discreetly and objectively. They can initiate a thorough investigation while maintaining confidentiality and protecting the rights of all involved parties.

Access to Resources: The charge nurse has access to resources and authority to take immediate action, such as securing medications, initiating patient assessments, and notifying appropriate personnel within the healthcare facility.

Collaboration and Support: The charge nurse can provide guidance and support to the reporting nurse, ensuring their concerns are addressed appropriately and that they feel safe in coming forward with their suspicions.

Rationale for other choices:

B. Reporting the incident directly to the hospital’s security department might be premature without first informing the charge nurse. The charge nurse can assess the situation, gather more information, and determine the most appropriate course of action, which may or may not involve security at this initial stage.

C. Requesting assistive personnel (AP) to monitor the other nurse’s actions is inappropriate. It places a burden on APs who are not trained or authorized to investigate such matters. It could also compromise the integrity of the investigation and potentially jeopardize patient safety.

D. Confronting the other nurse directly is not recommended. It could escalate the situation, create a hostile work environment, and potentially compromise the investigation. It is essential to follow established protocols and involve appropriate personnel to ensure a fair and thorough investigation.

A. Request NPO status for the client. B. Elevate the head of the bed to high Fowler’s. C. Measure the client’s temperature. D. Check the client’s respiratory rate and lung sounds.

Correct Answer is D

Explanation

NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.

Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.

It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.

Rationale for Choice B:

Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.

Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.

Rationale for Choice C:

Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.

While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.

The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:

Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.

Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate

Crackles in the lungs Shortness of breath Hypoxia

Early identification of these signs is crucial for prompt intervention and prevention of serious complications.

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A nurse is providing care to a group of patients in an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?

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Naxlex Comprehensive Predictor Exams

A nurse on the unit suspects that a colleague is extracting a small quantity of morphine from the syringe prior to administering it to the patient.What should the nurse do in this situation?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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