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 B
Explanation
Choice A
Bananas are incorrect. Bananas are naturally low in sodium.
Choice B
Ground sirloin is correct. For an older adult who needs to limit sodium intake, the nurse should encourage avoiding foods that are high in sodium. Processed meats, including ground meats like ground sirloin, are often higher in sodium due to added preservatives and flavourings. These additives can significantly contribute to sodium content. Encouraging the client to choose lean meats and to avoid processed meats can help reduce sodium intake.
Choice C
Cottage cheese is incorrect. While cottage cheese might contain some sodium, it's usually lower in sodium compared to processed meats.
Choice D
Broccoli is incorrect. Broccoli is a vegetable that is naturally low in sodium.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A
Generalized nonpitting edema is correct. Nonpitting edema could indicate fluid retention, and it's important to assess for signs of fluid overload, electrolyte imbalances, or underlying cardiac issues.
Choice B
Hypoactive bowel sounds in all 4 quadrants is correct. Hypoactive bowel sounds could suggest gastrointestinal motility issues, which could be a sign of gastrointestinal complications related to TPN.
Choice C
Redness at intravenous site is correct. Redness at the intravenous site could be indicative of infection, infiltration, or irritation. It's important to assess for signs of infection and ensure proper IV site care.
Choice D
Urinary output greater than 30 ml per hour is incorrect. While increased urinary output could indicate adequate hydration, it's not typically a concerning finding unless there are other signs of fluid imbalance. Top of Form
Choice E
Frequent productive cough is correct. A frequent productive cough could indicate respiratory issues, including aspiration pneumonia, which can be a complication of TPN.
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