A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

A history of gastroesophageal reflux disease.

A residual of 65 mL. 1 hr postprandial.

Sitting in high-Fowler's position during the feeding

Receiving a high-osmolarity formula.

Answer and Explanation

The Correct Answer is A

A. A history of gastroesophageal reflux disease: This factor places the client at a higher risk for aspiration. Patients with gastroesophageal reflux disease (GERD) may experience backflow of stomach contents, which can lead to aspiration, especially when receiving enteral feedings.

B. A residual of 65 mL, 1 hr postprandial: While monitoring residual volumes is important to assess tolerance to feeding, a residual of 65 mL alone does not inherently indicate a high risk for aspiration. It may suggest that the feeding rate needs adjustment but isn't a direct risk factor.

C. Sitting in high-Fowler's position during the feeding: This position is actually protective against aspiration, as it promotes better gastric emptying and reduces the likelihood of reflux.

D. Receiving a high-osmolarity formula: While high-osmolarity formulas can sometimes lead to gastrointestinal discomfort or diarrhea, they do not directly increase the risk of aspiration. Proper management of feeding administration is key.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Edema: While edema can occur in some patients, it is not a common or serious side effect of simvastatin. Clients should monitor for any unusual swelling, but it is not the primary concern associated with this medication.

B) Weight loss: Weight loss is not typically associated with simvastatin use. Clients should be aware of their weight but reporting weight loss alone is not usually necessary unless it is significant or accompanied by other concerning symptoms.

C) Muscle weakness: Simvastatin can lead to muscle-related side effects, including myopathy and rhabdomyolysis, which can present as muscle weakness. It is critical for clients to monitor for any unexplained muscle pain, tenderness, or weakness and report these symptoms to the provider, as early intervention can prevent serious complications.

D) Fever: Fever is not a typical side effect of simvastatin. While clients should report any signs of infection or unusual symptoms, fever alone is not specifically linked to the use of this medication and does not warrant immediate concern related to simvastatin therapy.

A. Ambulate the client 48 hr after the procedure. B. Provide a soft diet on the first postoperative day. C. Provide 60 mL (2 oz) of fluid intake every 5 min. D. Measure and compare abdominal girth daily.

Correct Answer is D

Explanation

A) Ambulate the client 48 hr after the procedure: Early ambulation is important to prevent complications such as deep vein thrombosis and promote recovery. However, ambulating the client 48 hours after the procedure may be too late. Early mobilization, usually within the first 24 hours, is encouraged.

B) Provide a soft diet on the first postoperative day: After gastric bypass surgery, the client typically starts with clear liquids and gradually progresses to a soft diet. Providing a soft diet on the first postoperative day is not appropriate and could cause complications.

C) Provide 60 mL (2 oz) of fluid intake every 5 min: Fluid intake should be carefully monitored and gradually increased. Providing 60 mL of fluid every 5 minutes is excessive and could lead to discomfort or complications such as dumping syndrome.

D) Measure and compare abdominal girth daily: Measuring and comparing abdominal girth daily helps monitor for signs of complications such as internal bleeding or anastomotic leaks. This intervention is crucial for early detection and prompt management of potential issues

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider?

Correct Answer is C

Explanation

A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

A nurse is caring for a client who has systemic lupus erythematosus. Which of the following client findings should the nurse expect?

A nurse is providing teaching to an older adult client who has a seizure disorder and a new prescription for phenytoin. Which of the following instructions should the nurse include?

A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take?

A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?

A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care?

A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching?