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.

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Correct Answer is C

Explanation

A. Ask a nursing student who speaks the same language as the client to translate: This is not appropriate, as the nursing student may not be trained in medical terminology or confidentiality, which could lead to miscommunication and potential breaches of privacy.

B. Allow the client's partner to translate: While the partner may understand the language, this approach can create conflicts of interest, and they may not be able to convey the full medical context or sensitive information accurately.

C. Request a female interpreter through the facility: This is the best action. Using a trained, professional interpreter ensures that the communication is accurate and confidential, allowing the nurse to gather necessary admission data effectively while respecting the client's comfort and cultural needs.

D. Have the client's child translate: It is not appropriate to involve a child in medical discussions, as they may not fully understand the context or terminology and could feel overwhelmed by the responsibility.

A. Direct statements to the interpreter. B. Pause in the middle of sentences. C. Speak in a normal voice at a natural pace. D. Use gestures when speaking with the client.

Correct Answer is C

Explanation

A) Direct statements to the interpreter: The nurse should speak directly to the client rather than the interpreter. While the interpreter facilitates communication, maintaining direct eye contact and addressing the client fosters a more personal and respectful interaction.

B) Pause in the middle of sentences: Pausing mid-sentence can confuse both the interpreter and the client, potentially leading to misunderstandings. It’s better to complete thoughts and allow the interpreter to relay the information in full.

C) Speak in a normal voice at a natural pace: This action is appropriate as it ensures that the client can understand the information being communicated. Speaking normally allows the interpreter to accurately convey the message without distortion or misinterpretation, which is essential for effective communication.

D) Use gestures when speaking with the client: While gestures can help with communication, they should be used carefully, as they may not always translate effectively across cultures. Relying too much on gestures can lead to misunderstandings or misinterpretations of the intended message. It's best to use clear verbal communication first, supplemented by gestures only as needed.

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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

Correct Answer is C

Explanation

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

Correct Answer is C

Explanation

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