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) A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities: While this client requires assessment, their condition is not immediately life-threatening. Orthostatic hypotension and edema need to be evaluated, but they are not acute emergencies.

B) A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F): This client needs attention due to the infection and fever, but it is not as critical as the potential cardiac event presented in option C.

C) A client who has left shoulder pain and S-T elevation on a 12-lead ECG: This client is exhibiting signs that may indicate an acute myocardial infarction (heart attack). S-T elevation on an ECG is a significant finding and suggests that this client could be experiencing a serious cardiac event, making it the priority for assessment.

D) A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10: While this client is in pain and requires care, the priority in emergency situations is often given to conditions that are life-threatening, such as those related to cardiac function. Therefore, this client can be assessed after addressing the potential cardiac emergency.

A. "Use a cane when walking to maintain your balance." B. "Engage in a rigorous exercise program to maintain muscle tone." C. "Plan to take a hot bath once a week to reduce stress." D. "Place a scatter rug in your bathroom to prevent falling."

Correct Answer is A

Explanation

A. "Use a cane when walking to maintain your balance.": This statement is appropriate. Using a cane can help clients with multiple sclerosis (MS) maintain balance and prevent falls, which is particularly important as they may experience coordination and mobility issues.

B. "Engage in a rigorous exercise program to maintain muscle tone.": This is not advisable for someone with MS. While exercise is important, it should be tailored to the individual's capabilities and should not be overly rigorous, as fatigue is a common symptom of MS.

C. "Plan to take a hot bath once a week to reduce stress.": While relaxation is beneficial, many individuals with MS may find that heat exacerbates their symptoms. It would be better to recommend warm (not hot) baths and to monitor for any adverse effects.

D. "Place a scatter rug in your bathroom to prevent falling.": This is unsafe advice. Scatter rugs can increase the risk of falls, which is particularly concerning for clients with MS. It is better to suggest removing rugs and using non-slip mats to enhance safety in the home environment.

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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?

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