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 B
Explanation
A. Incorrect. Sitting on the bed next to the client may infringe on the client's personal space and comfort.
B. Correct. Sitting in a chair next to the bed at the client's eye level helps establish a more comfortable and empathetic interaction.
C. Incorrect. Standing at the side of the bed may be perceived as less engaging and could create a power dynamic.
D. Incorrect. Standing at the foot of the bed may be uncomfortable for the client and may impede effective communication.
Correct Answer is C
Explanation
Choice C rationale:
Recommending scrambled eggs is appropriate for a client with dysphagia caused by a stroke. Scrambled eggs have a soft and moist texture, making them easier to swallow for individuals with difficulty swallowing. It is crucial to choose foods that are easy to chew and swallow, as well as foods that can be easily moistened with sauces or gravies to aid in swallowing.
Choice A rationale:
Crispy rice bars are dry and hard, posing a significant risk for individuals with dysphagia. Foods that are dry, crunchy, or crumbly can be difficult to swallow and may lead to choking, especially for individuals with impaired swallowing abilities. Therefore, crispy rice bars are not a suitable choice for a client with dysphagia.
Choice B rationale:
Peanut butter, especially when consumed without added moisture or in large amounts, can be thick and sticky, making it challenging to swallow, especially for individuals with dysphagia. It can adhere to the walls of the throat, causing discomfort and difficulty in swallowing. While peanut butter can be a good source of protein, it is not an ideal choice for someone with swallowing difficulties.
Choice D rationale:
Soda crackers are dry and can be crumbly, making them a poor
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