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?

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

A history of gastroesophageal reflux disease.

A residual of 65 mL 1 hr postprandial.

Receiving a high-osmolarity formula.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.

Choice B rationale:

A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.

Choice C rationale:

A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.

Choice D rationale:

Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.

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Correct Answer is C

Explanation

Choice A rationale:

Upper extremity hypotension is not a common finding in coarctation of the aorta. Coarctation of the aorta typically results in narrowing of the aorta, leading to decreased blood flow to the lower part of the body. This can cause weak or absent femoral pulses and lower extremity hypotension, not upper extremity hypotension.

Choice B rationale:

Frequent nosebleeds are not directly associated with coarctation of the aorta. The symptoms of coarctation of the aorta are primarily related to decreased blood flow to the lower extremities, leading to symptoms such as weak femoral pulses, lower extremity hypotension, and leg cramping or pain.

Choice D rationale:

Increased intracranial pressure is not a typical finding in coarctation of the aorta. Coarctation of the aorta affects blood flow to the lower part of the body and does not directly impact intracranial pressure.

A. Placental abruption. B. Cervical insufficiency. C. Seizures. D. Hypoglycemia. E. Heart failure.

Correct Answer is ["A","C"]

Explanation

The correct answers are Choices A and C.

Choice A rationale: Severe hypertension in pregnancy disrupts placental perfusion and vascular integrity, increasing risk of placental abruption due to premature separation and hemorrhage, threatening both maternal and fetal outcomes.

Choice B rationale: Cervical insufficiency is linked to structural weakness or trauma, not hypertension; it typically presents with painless dilation and is unrelated to elevated blood pressure or vascular compromise.

Choice C rationale: Hypertensive encephalopathy and preeclampsia can progress to eclampsia, marked by seizures. Elevated BP increases cerebral edema and excitability, triggering convulsions if unmanaged.

Choice D rationale: Hypoglycemia is not a direct consequence of hypertension; it’s more associated with insulin dysregulation, poor intake, or medication effects, not elevated blood pressure.

Choice E rationale: Heart failure may occur in chronic hypertension but is less acute than seizure or abruption risk in this context. No signs of fluid overload or cardiac decompensation are present in the vitals.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for an infant who has coarctation of the aorta.Which of the following should the nurse identify as an expected finding?

Correct Answer is C

Explanation

Correct Answer is ["A","C"]

Explanation

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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?