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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Directing anyone who becomes angry to leave the room may escalate tensions and hinder resolution.
B: Establishing demands from each party can create a confrontational atmosphere where parties are more focused on winning than resolving the conflict.
C: In resolving staff conflicts, facilitating discussion until all parties agree is a constructive strategy that promotes understanding and collaboration. This approach encourages open communication, allows for the expression of different viewpoints, and works towards a consensus that respects everyone's needs and concerns.
D: Determining fault can increase defensiveness and hinder collaboration in resolving the conflict. It is counterproductive as it places blame, which can lead to defensiveness and hinder the resolution process.
Correct Answer is A
Explanation
A. Raised facial rash, often in a "butterfly" distribution across the cheeks and bridge of the nose, is a characteristic manifestation of systemic lupus erythematosus.
B. Hemangiomas are not typically associated with systemic lupus erythematosus.
C. Kaposi's sarcoma lesions are associated with immunosuppression, such as in HIV infection, and are not a typical finding in systemic lupus erythematosus.
D. Psoriasis is a separate autoimmune condition characterized by red, scaly patches on the skin and is not typically associated with systemic lupus erythematosus.
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