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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) “You should give your child a clear liquid diet for 24 hr.”:A clear liquid diet is not typically required following a cardiac catheterization. The child can usually resume a regular diet unless otherwise instructed by the healthcare provider.
B) “Your child can take a tub bath this evening.”:Tub baths should be avoided immediately after a cardiac catheterization to prevent infection at the catheter insertion site. Sponge baths are usually recommended until the site has healed.
C) “Your child should stay out of school for 7 days following the procedure.”:While some rest is necessary, staying out of school for 7 days is generally not required. The child can usually return to school within a few days, depending on their recovery and the healthcare provider’s advice.
D) “You should remove your child’s pressure dressing tomorrow.”:Removing the pressure dressing the day after the procedure is a common instruction. It allows the site to be inspected for any signs of infection or complications and ensures proper healing.
Correct Answer is A
Explanation
A) Document the client's condition every 15 min: This is an appropriate guideline for the use of restraints. Regular monitoring and documentation are essential to ensure the client's safety and well-being, and every 15 minutes is a commonly recommended interval.
B) Attach the restraint to the bed's side rails: Restraints should not be attached to the side rails, as this can pose a risk of injury if the rails are moved. Instead, they should be secured to a stationary part of the bed frame.
C) Remove the client's restraint every 4 hr: This guideline is not appropriate. Restraints should be removed at least every 2 hours to assess the client's needs and allow for movement, unless otherwise specified by a healthcare provider.
D) Request a PRN restraint prescription for clients who are aggressive: Restraints should not be used as a PRN intervention. They require a specific order based on an assessment of the client’s condition and should only be used when less restrictive measures have failed. Regular assessment and a clear plan of care are critical for the appropriate use of restraints.
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