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.

Answer and Explanation

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.

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Correct Answer is ["595"]

Explanation

To calculate the fluid intake, you need to convert each type of drink to millilitres (mL) and then sum them up:

Oatmeal: Oatmeal is usually consumed as a solid, so it doesn't contribute to fluid intake.

Cup of milk: Depending on the size of the cup, let's assume it's 240 mL (a common serving size for a cup of milk).

12 ounces of coffee: Convert ounces to millilitres. 1 fluid ounce is approximately 29.5735 mL, so 12 ounces is roughly 354.882 mL.

Total fluid intake = Milk + Coffee Total fluid intake = 240 mL + 354.882 mL Total fluid intake = approx595mL

A. 24-hour food recall, food preferences, and allergies. B. Body mass index (BMI) and serum albumin level. C. Triceps skin fold and mid-arm circumference. D. Weight loss history and body surface area (BSA).

Correct Answer is B

Explanation

Choice A

24-hour food recall, food preferences, and allergies is incorrect. While these factors are important for understanding the client's dietary habits and possible dietary restrictions, they do not directly provide information about the client's current nutritional status or overall nutritional health.

Choice B

Body mass index (BMI) and serum albumin level is correct. Body mass index (BMI) and serum albumin level are commonly used parameters to assess a client's nutritional status. These measures provide valuable information about the client's weight, muscle mass, and protein status. Let's break down the options:

Choice C

Triceps skin fold and mid-arm circumference is incorrect. These measurements can provide information about the client's body composition and muscle mass. However, they are not as commonly used as BMI and serum albumin level for assessing nutritional status.

Choice D

Weight loss history and body surface area (BSA) is incorrect. Weight loss history is relevant for understanding changes in the client's weight over time, which can indicate potential malnutrition. However, it's not as comprehensive as BMI, which considers both weight and height. Body surface area (BSA) is not typically used to assess nutritional status.

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Which client is at greatest risk for aspiration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only to 0 decimal places)

Correct Answer is ["595"]

Explanation

The nurse is admitting an older client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

Correct Answer is B

Explanation

When conducting diet teaching for a client diagnosed with hypokalaemia, which foods should the nurse encourage the client to eat?

The nurse is providing dietary education to a client newly diagnosed with Type 2 diabetes mellitus. Which information should the nurse provide?

A young adult client with a history of iron deficiency anaemia has a haemoglobin of 10.5 g/dL (6.52 mmol/L). Which food choice should the nurse recommend to this client? Reference Range Haemoglobin (Hgb) [Reference Range: Male: 14 to 18 g/dL or 8.7 to 11.2 mmol/L]

A client who is receiving antineoplastic chemotherapy has lost 25% of total body weight and is having difficulty eating because of stomatitis. In planning care for this client which diet should the nurse recommend?

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

A client is receiving a continuous gastric tube feeding at 80 mL/hour. The nurse records the client's gastric residual volume as 325 mL during each of two consecutive hourly measurements. What assessment should the nurse complete before contacting the healthcare provider?

A client has a serum sodium level of 155 mEq/L (155 mmol/L). The nurse should encourage the client to make which selection from the lunch menu? Reference Range Sodium [Reference Range: Adult 136 to 145 mEq/L or 136 to 145 mmol/L]