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 C

Explanation

A. Incorrect. Placing a towel roll under the client's neck is a preventive measure to maintain proper cervical alignment, but it does not specifically address contracture prevention.

B. Incorrect. This can promote flexion of the knees, which may actually contribute to knee flexion contractures over time. While it might be comfortable for the client, it's not a preventive measure against contractures.

C. Correct. Orthotics can help maintain proper alignment of the foot and ankle, preventing foot drop and other related contractures. They are designed to support joints and muscles, minimizing the risk of stiffness and contracture formation.

D. Incorrect. Aligning a trochanter wedge between the client's legs might help prevent external rotation of the hips but does not specifically address contracture prevention.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

The client is at highest risk for developing mastitis evidenced by the client's visible cracknoted on left nipple

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?

Correct Answer is C

Explanation

A nurse is caring for a postpartum client in an outpatient setting. Exhibits A nurse is caring for a postpartum client in an outpatient setting. Complete the following sentence by using the lists of options. The client is at highest risk for developing evidenced by the client's

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

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