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 D

Explanation

A. Incorrect. Clear liquids are usually introduced slowly and progressively, but 6 hours postoperative might be too soon for this intervention.

B. Incorrect. Cromolyn nebulized solution is used to prevent asthma symptoms triggered by certain factors, not for postoperative care.

C. Incorrect. Applying a warm compress to the operative site might not be appropriate for the immediate postoperative period, especially in the case of appendicitis.

D. Correct. Administering analgesics on a scheduled basis helps manage postoperative pain and provides effective pain relief, promoting comfort and recovery.

A. Perform a sterile dressing change for a client who has an abdominal wound. B. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus. C. Perform an admission assessment for a client who is scheduled for surgery. D. Complete the Glasgow Coma Scale for a client who has an evolving stroke.

Correct Answer is A

Explanation

A. Correct. Performing a sterile dressing change falls within the scope of practice for a licensed practical nurse (LPN).

B. Incorrect. Discharge teaching often involves complex information and considerations, which are typically better suited for a registered nurse.

C. Incorrect. An admission assessment requires comprehensive assessment skills that are typically performed by registered nurses.

D. Incorrect. Completing assessments related to complex neurological changes, such as the Glasgow Coma Scale for a stroke, is typically within the scope of a registered nurse.

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