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 C
Explanation
A. "Limit your child's potassium intake while she is taking this medication.": This statement is incorrect. In fact, potassium intake should generally be adequate because digoxin can lead to increased potassium loss, and low potassium levels can increase the risk of digoxin toxicity.
B. “Repeat the dose if your child vomits within 1 hour after taking the medication.": This statement is not recommended. The nurse should advise parents to contact their healthcare provider for guidance on whether to administer a repeat dose after vomiting, as it depends on the individual situation and timing.
C. "Have your child drink a small glass of water after swallowing the medication.": This statement is appropriate as it can help ensure that the medication is swallowed properly and aids in its absorption. Adequate hydration is important for all medications.
D. "You can add the medication to a half-cup of your child's favorite juice.": This is not advisable because mixing digoxin with juice can alter the absorption of the medication. It's generally better to administer it alone to ensure proper dosing and effectiveness.
Correct Answer is D
Explanation
A) Use clothing with buttons and zippers: This may create frustration for clients with dementia, who may struggle with complex clothing. Instead, simpler clothing options, like pull-on pants, may be more suitable.
B) Engage the client in activities that increase sensory stimulation: While some sensory stimulation can be beneficial, overwhelming sensory input may lead to confusion or agitation. It’s important to find a balance that suits the individual’s needs.
C) Discourage physical activity during the day: This is incorrect. Encouraging physical activity during the day can help improve mood, reduce restlessness, and promote better sleep at night.
D) Establish a toileting schedule for the client: This is the correct answer. A consistent toileting schedule can help manage incontinence and reduce anxiety related to bathroom needs, providing a sense of routine and security for clients with dementia.
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