Which client is at greatest risk for aspiration?
Client with a nasogastric tube to low, intermittent suction.
Client who has sensory aphasia and is receiving a clear liquid diet.
Client receiving 30% oxygen via a non-rebreather face mask.
Client experiencing dysphagia who is prescribed a full liquid diet.
The Correct Answer is B
Choice A
Client with a nasogastric tube to low, intermittent suction is not correct. While there is a risk of aspiration with a nasogastric tube in place, the tube is intended to help drain stomach contents, reducing the risk of aspiration. However, if the tube is not properly positioned or managed, there could still be some risk.
Choice B
Client who has sensory aphasia and is receiving a clear liquid diet is correct. Sensory aphasia refers to a language disorder that affects a person's ability to understand language and communication. This client may have difficulty swallowing safely and effectively, which increases the risk of aspiration. Additionally, a clear liquid diet consists of thin liquids that are more likely to be aspirated compared to thicker fluids.
Choice C
Client receiving 30% oxygen via a non-rebreather face mask is not correct. Oxygen therapy can increase the risk of drying the airways and potentially increasing the risk of aspiration, but if the oxygen mask is properly fitted and humidified, the risk may be minimized.
Choice D
Client experiencing dysphagia who is prescribed a full liquid diet is not correct. Dysphagia refers to difficulty swallowing, which can increase the risk of aspiration. However, a full liquid diet includes thicker liquids that are less likely to be aspirated compared to thin liquids. Still, the risk of aspiration exists, especially if the client has severe dysphagia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A
Demonstrating correct measurement of the tube insertion length is the first priority. Inserting a nasogastric tube to the appropriate length is crucial for ensuring that the tube reaches the stomach and is not inserted too far. Incorrect insertion length can lead to complications, discomfort, or potential harm to the patient. Therefore, demonstrating and ensuring the correct measurement of the tube insertion length takes priority.:
Choice B
Reminding the nurse to apply lubricant to the tube before insertion is not first priority. Applying lubricant helps ease the insertion process, but it is not the most critical step to prioritize initially.
Choice C
Confirming that the nurse has auscultated the client's bowel sounds is not the first priority. Bowel sounds assessment is important to ensure proper placement, but this step can be done after ensuring the correct measurement of the insertion length.
Choice D
Elevating the head of the bed before the nurse inserts the tube is not the first priority: Elevating the head of the bed helps facilitate the passage of the tube into the stomach, but it is not the first priority in this context.
Correct Answer is B
Explanation
Choice A
Apples and blueberries are incorrect. While apples and blueberries are sources of nutrients, they are not as high in potassium as avocados and bananas.
Choice B
Avocados and bananas are correct. Chronic kidney disease (CKD) often requires dietary modifications to manage electrolyte and mineral imbalances. In CKD stage 4, the kidney's ability to filter waste and excess substances from the blood is significantly impaired. Therefore, certain foods that are high in potassium should be limited to prevent hyperkalaemia (elevated blood potassium levels).
Choice C
Cherries and cranberries are incorrect. Cherries and cranberries are also sources of nutrients, but their potassium content is not as high as that of avocados and bananas.
Choice D
Carrots and green beans are incorrect. Carrots and green beans are vegetables that are generally lower in potassium compared to fruits like avocados and bananas.
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