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

Answer and Explanation

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.

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

Explanation

A. Wheezes - Latex Allergy. Wheezing is often associated with allergic reactions, including latex allergy. Latex allergy can cause airway constriction and result in wheezing.

B. Tachycardia - All Thr ee Conditions (Malignant Hyperthermia, Latex Allergy, Hypovolemic Shock). Tachycardia can be a common response to stress or physiological changes. In malignant hyperthermia, tachycardia can occur due to the hypermetabolic state. Latex allergy can cause an anaphylactic reaction leading to tachycardia. In hypovolemic shock, the heart rate increases to compensate for decreased blood volume.

C. Urticaria - Latex Allergy. Urticaria (hives) is a classic sign of an allergic reaction, including latex allergy.

D. Hypercapnia - Malignant Hyperthermia. Hypercapnia (elevated levels of carbon dioxide in the blood) can be a sign of malignant hyperthermia due to increased muscle metabolism and metabolic acidosis.

E. Muscle Rigidity - Malignant Hyperthermia. Muscle rigidity is a hallmark sign of malignant hyperthermia, a rare but potentially life-threatening reaction to certain medications used during anesthesia.

A. Call in additional medical-surgical unit nursing care staff. B. Recommend to the provider specific acute care clients for discharge. C. Determine the medical needs of incoming clients through the emergency department. D. Act as a liaison between the facility and the media.

Correct Answer is C

Explanation

A. While additional staffing might be necessary, the nurse's priority in a mass casualty event is to assess and provide care to incoming clients.
B. Discharging specific acute care clients may not be the immediate priority in a mass casualty event.
C. Correct. In a mass casualty event, the nurse should collaborate with the emergency department to determine the medical needs and prioritize care for incoming clients.
D. Acting as a liaison between the facility and the media may not be the immediate priority during a mass casualty event.

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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

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

Explanation

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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