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
Sitting in high-Fowler's position during the feeding
A history of gastroesophageal reflux disease
Receiving a high-osmolarity formula
The Correct Answer is C
A. Incorrect. A residual of 65 mL may indicate delayed gastric emptying, but it alone does not directly correlate with an increased risk of aspiration unless it leads to significant overdistension or the client is unable to tolerate further feedings.
B. Incorrect. Sitting in high Fowler's position during feeding is actually a preventive measure against aspiration.
C. Correct. his factor increases the risk for aspiration. Clients with gastroesophageal reflux disease (GERD) are more prone to refluxing contents from the stomach into the esophagus, which can lead to aspiration, especially during or after feedings.
D. Incorrect. The osmolarity of the formula might affect tolerance but is not directly related to aspiration risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Watery stool is not indicative of paralytic ileus. Paralytic ileus is a condition characterized by the inhibition of bowel peristalsis, leading to symptoms such as abdominal distention, constipation, and lack of bowel sounds.
Choice B rationale:
Dizziness is not a specific symptom of paralytic ileus. Dizziness can be caused by various factors and is not directly related to the gastrointestinal condition.
Choice C rationale:
Abdominal distention is the correct choice. Paralytic ileus often presents with abdominal distention due to the accumulation of gas and fluids in the intestines. This distention can cause discomfort and a visible increase in the size of the abdomen.
Choice D rationale:
Oliguria, a decreased urine output, is not a typical symptom of paralytic ileus. It is more indicative of kidney-related issues or dehydration rather than gastrointestinal problems.
Correct Answer is B
Explanation
A. Incorrect. Covering the adolescent with a thermal blanket may worsen hyperthermia.
B. Correct. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Incorrect. Submerging the feet in ice water is not recommended due to the risk of causing shock.
D. Incorrect. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
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