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.
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) The statement about returning to school once the fever has subsided is not sufficient for varicella. Children should not return until the lesions have crusted over to prevent spreading the infection.
B) The recommendation that the child can return to school once the lesions have crusted over is accurate. Varicella is contagious from 1 to 2 days before the rash appears until all lesions have crusted over, which usually occurs about 6 days after the onset of the rash.
C) A negative titer result is not necessary for a child to return to school. Immunity can be confirmed through vaccination history or prior infection; thus, this statement is misleading.
D) Since varicella is a viral infection, antibiotics are not indicated for treatment. Therefore, stating that the child can return to school 24 hours after beginning antibiotics is incorrect and could lead to misunderstanding about the management of the illness.
Correct Answer is D
Explanation
A. Bradypnea: This refers to a slower than normal respiratory rate, which is not a typical manifestation of pulmonary congestion. In fact, pulmonary congestion often leads to tachypnea (increased respiratory rate).
B. Jugular vein distention: This is more indicative of right-sided heart failure or fluid overload rather than left-sided heart failure, where the primary issue is related to pulmonary congestion.
C. Weight gain: While weight gain can occur due to fluid retention in heart failure, it is not specific to pulmonary congestion and can be seen in both left-sided and right-sided heart failure.
D. Frothy, pink sputum: This is a classic manifestation of pulmonary congestion and indicates the presence of fluid in the lungs, often seen in left-sided heart failure. The pink color is due to the presence of blood, which may leak into the alveoli due to increased pressure. This finding is critical and should be closely monitored.
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