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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?

A.

A residual of 65 mL 1 hr postprandial.

B.

A history of gastroesophageal reflux disease.

C.

Receiving a high-osmolarity formula.

D.

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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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"B"}}

Explanation

A. Establishing a regular sleep-wake schedule can help regulate circadian rhythms and improve sleep quality, which is beneficial for managing insomnia. B. Napping during the day can disrupt the client's ability to sleep at night, exacerbating insomnia. It's generally recommended to avoid daytime naps for individuals experiencing difficulty sleeping. C. Sleeping in later in the morning can disrupt the client's sleep-wake cycle and contribute to difficulty falling asleep at night. Consistency in sleep-wake times is important for managing insomnia. D. Rising slowly from a sitting position can help prevent orthostatic hypotension, especially for clients taking trazodone, which can cause dizziness or lightheadedness upon standing. E. Trazodone is a medication that may have risks associated with use during pregnancy, so it's important for the client to inform their provider if they are pregnant or planning to become pregnant. F. Loss of appetite is a concern, but encouraging high-calorie finger foods may not address the underlying issue. It's important to address the root cause of the appetite loss and provide appropriate interventions, which may include dietary counseling and addressing stress. G. There is no indication in the scenario that fermented or aged foods would negatively affect the client's condition or interact with trazodone. It's important to focus on addressing the primary concerns of stress, difficulty sleeping, and loss of appetite.

Correct Answer is C

Explanation

A. Negligence refers to the failure to provide care that a reasonably prudent person would have under similar circumstances, resulting in harm to the patient.
B. Battery involves the intentional harmful or offensive contact with a person without their consent. While similar to assault, battery involves actual physical contact, such as forcibly inserting a urinary catheter without consent.
C. Assault occurs when a threat of harmful or offensive contact is made, causing fear or apprehension in the victim. In this scenario, the newly licensed nurse's statement of

inserting a urinary catheter without consent if the client does not void constitutes an act of assault.
D. Libel involves making defamatory statements in written or published form, which is not applicable in this scenario.

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