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 residual of 65 mL 1 hr postprandial.

A history of gastroesophageal reflux disease.

Receiving a high-osmolarity formula.

Sitting in high-Fowler's position during the feeding.

Answer and Explanation

The Correct Answer is B

A.   This amount of residual is generally considered safe; guidelines often cite higher residuals (e.g., >100 mL) as concerning.
B.   Clients with a history of gastroesophageal reflux disease (GERD) are at increased risk for aspiration, particularly when lying flat, because the lower esophageal sphincter may not function properly, allowing stomach contents to move back into the esophagus.
C.   While high-osmolarity formulas can contribute to diarrhea, they are not directly linked to an increased risk of aspiration.
D.   Sitting in a high-Fowler’s position (semi-upright) during feedings is actually recommended to reduce the risk of aspiration.

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Correct Answer is A

Explanation

A. Uneven shoulder and pelvic heights are classic signs of scoliosis, visible during a physical examination where one shoulder or hip may appear higher than the other.
B. Mild pain in the hip region is not a specific indicator of scoliosis.

C. Exaggerated curvature of the sacrum is not a specific indicator of scoliosis.

D. Limited range-of-motion of the hips is not a specific indicator of scoliosis

A. Tachycardia B. Shivering C. Flushing D. Restlessness

Correct Answer is B

Explanation

A: Tachycardia might occur due to the fever itself but isn't a specific reaction to the cooling method.
B: Shivering is an adverse reaction because it indicates that the body is trying to generate heat to counteract the cooling effect of the blanket, which can increase metabolic demand and is counterproductive.
C: Flushing is typically related to fever or other causes but not directly to the adverse reaction of cooling.
D: Restlessness can be caused by discomfort or the fever itself, not specifically by cooling.

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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

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