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. Serum HDL (high-density lipoprotein) of 35 mg/dl (0.91 mmol/L). B. Serum HbA1c (glycosylated haemoglobin) of 4.8% (0.05). C. BMI (body mass index) of 22 kg/m2. D. Total serum calcium of 10 mg/dl (2.5 mmol/L).

Correct Answer is A

Explanation

Choice A

Serum HDL (high-density lipoprotein) of 35 mg/dL (0.91 mmol/L). Among the options provided, a serum HDL level of 35 mg/dL (0.91 mmol/L) is the assessment data that indicates the need for referral to a nutritionist. HDL is often referred to as "good" cholesterol because it helps remove excess cholesterol from the bloodstream, reducing the risk of cardiovascular disease. In this case, the HDL level of 35 mg/dL is below the recommended reference range for females (greater than 55 mg/dL or greater than 0.91 mmol/L), which could suggest a potential need for dietary and lifestyle interventions to improve cardiovascular health.

Choice B

Serum HbA1c (glycosylated haemoglobin) of 4.8% (0.05) is incorrect. This HbA1c level is within the normal reference range (4% to 5.9%) and indicates good blood sugar control.

Choice C

BMI (body mass index) of 22 kg/m² is incorrect. A BMI of 22 is within the normal weight range and might not necessarily indicate the need for a nutritionist referral.

Choice D

Total serum calcium of 10 mg/dL (2.5 mmol/L) is incorrect. This calcium level is within the normal reference range and might not require a nutritionist referral, unless there are other specific concerns related to calcium intake.

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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

Correct Answer is A

Explanation

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