A nurse is providing care to a group of patients in an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?
A patient with a colostomy.
A patient with an ileostomy.
A patient receiving enteral feedings through an NG tube.
A patient who has a chest tube following a motor vehicle crash.
The Correct Answer is C
Choice A rationale:
A colostomy is a surgical procedure that creates an opening in the colon (large intestine) to divert stool through the abdomen. While a colostomy can affect bowel function, it does not directly increase the risk of aspiration. This is because the colon is located further down the digestive tract and does not directly involve the airway.
Choice B rationale:
An ileostomy is a surgical procedure that creates an opening in the ileum (small intestine) to divert stool through the abdomen. Similar to a colostomy, an ileostomy does not directly increase the risk of aspiration because the ileum is also located further down the digestive tract and does not involve the airway.
Choice C rationale:
Enteral feedings, also known as tube feedings, involve delivering nutrients directly into the stomach or small intestine through a tube. Patients receiving enteral feedings through a nasogastric (NG) tube are at a significantly higher risk of aspiration for several reasons:
Impaired swallowing mechanisms: Many patients who require enteral feedings have impaired swallowing mechanisms, which can increase the risk of food or liquid entering the airway instead of the esophagus.
Tube placement: The NG tube itself can potentially irritate the esophagus or interfere with the normal closure of the upper esophageal sphincter, which can increase the risk of reflux and aspiration.
Feeding formula: Enteral feeding formulas are often thin and liquid-like, which can make them easier to aspirate than thicker liquids or solid foods.
Positioning: Patients receiving enteral feedings are often in a reclined position, which can make it easier for fluids to travel back up the esophagus and into the airway.
Choice D rationale:
A chest tube is a drainage tube inserted into the chest cavity to remove air or fluid. While a chest tube can affect respiratory function, it does not directly increase the risk of aspiration. This is because the chest tube drains fluid from the pleural space, which surrounds the lungs, and does not directly involve the airway or digestive tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Irrigating the tubing with sterile normal saline solution is not a routine part of closed-wound drainage system care.
It's usually only done if there's evidence of a blockage or infection, and only under the direction of a healthcare provider. Unnecessary irrigation could introduce bacteria into the system and increase the risk of infection.
It could also disrupt the delicate balance of fluids in the wound and delay healing.
Choice B rationale:
Replacing the drainage plug after releasing hand pressure on the device is not correct. The drainage plug should actually be replaced before releasing hand pressure.
This is to prevent air from entering the system, which could disrupt the vacuum and impair drainage.
Choice D rationale:
Emptying the reservoir once per day is not frequent enough.
The reservoir should be emptied whenever it becomes full, which could be more often than once a day, depending on the amount of drainage.
Allowing the reservoir to become too full could put pressure on the wound and impede healing.
Choice C rationale:
Fully re-collapsing the reservoir after emptying it is essential to maintain the vacuum that promotes drainage. If the reservoir is not fully re-collapsed, the vacuum will be lost, and drainage will slow or stop.
This could lead to fluid accumulation in the wound, which could increase the risk of infection and delay healing.
Correct Answer is B
Explanation
Choice A rationale:
Tenderness to touch is a common finding in wounds healing by secondary intention. It's often due to inflammation, which is a normal part of the healing process. The inflammation brings in cells and substances that promote healing. However, increased tenderness, especially when accompanied by other signs of infection, should be reported.
Choice B rationale:
A halo of erythema on the surrounding skin is a sign of infection. This is a serious complication that can delay healing and lead to further complications. The erythema indicates that the infection is spreading beyond the wound edges and needs prompt attention.
Choice C rationale:
Drainage of serosanguineous fluid is also common in wounds healing by secondary intention. This fluid is a mixture of serum (clear yellowish fluid) and blood. It's a sign that the wound is cleaning itself and new tissue is forming. While excessive drainage or a change in color or odor could signal a problem, drainage itself is not necessarily a cause for concern.
Choice D rationale:
Pink, shiny tissue with a granular appearance is a sign of healthy granulation tissue. This is a type of tissue that forms during the healing process. It's rich in blood vessels and collagen, which are essential for wound healing. The presence of granulation tissue indicates that the wound is healing well.
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