Which client is at greatest risk for aspiration?

Client with a nasogastric tube to low, intermittent suction.

Client who has sensory aphasia and is receiving a clear liquid diet.

Client receiving 30% oxygen via a non-rebreather face mask.

Client experiencing dysphagia who is prescribed a full liquid diet.

Answer and Explanation

The Correct Answer is B

Choice A

Client with a nasogastric tube to low, intermittent suction is not correct. While there is a risk of aspiration with a nasogastric tube in place, the tube is intended to help drain stomach contents, reducing the risk of aspiration. However, if the tube is not properly positioned or managed, there could still be some risk.

Choice B

Client who has sensory aphasia and is receiving a clear liquid diet is correct. Sensory aphasia refers to a language disorder that affects a person's ability to understand language and communication. This client may have difficulty swallowing safely and effectively, which increases the risk of aspiration. Additionally, a clear liquid diet consists of thin liquids that are more likely to be aspirated compared to thicker fluids.

Choice C

Client receiving 30% oxygen via a non-rebreather face mask is not correct. Oxygen therapy can increase the risk of drying the airways and potentially increasing the risk of aspiration, but if the oxygen mask is properly fitted and humidified, the risk may be minimized.

Choice D

Client experiencing dysphagia who is prescribed a full liquid diet is not correct. Dysphagia refers to difficulty swallowing, which can increase the risk of aspiration. However, a full liquid diet includes thicker liquids that are less likely to be aspirated compared to thin liquids. Still, the risk of aspiration exists, especially if the client has severe dysphagia.

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Correct Answer is B

Explanation

Choice A

Canned cream of mushroom soup, tuna salad, and water is inappropriate. Canned soups and processed foods like canned cream soups can be high in sodium. Tuna salad might also have added salt.

Choice B
B. Bacon, lettuce, and tomato sandwich, grapes, and skim milk is the appropriate selection. A serum sodium level of 155 mEq/L (155 mmol/L) is higher than the normal reference range (136 to 145 mEq/L or 136 to 145 mmol/L), indicating hypernatremia or high blood sodium levels. In this case, it's important for the client to choose foods that are lower in sodium to help manage their sodium intake.

Choice C

Taco salad, refried beans, low-fat ice cream, and coffee is inappropriate. Taco salad can contain salty ingredients, and refried beans can also be high in sodium. Processed meats and sauces used in tacos can contribute to sodium intake.

Choice D

Chicken salad on toast, fruit-flavoured yogurt, and iced tea is inappropriate. Chicken salad and some breads might contain added salt. Fruit-flavoured yogurts can also have added sugars, and iced tea can vary in sodium content depending on how it's prepared.

A. 24-hour food recall, food preferences, and allergies. B. Body mass index (BMI) and serum albumin level. C. Triceps skin fold and mid-arm circumference. D. Weight loss history and body surface area (BSA).

Correct Answer is B

Explanation

Choice A

24-hour food recall, food preferences, and allergies is incorrect. While these factors are important for understanding the client's dietary habits and possible dietary restrictions, they do not directly provide information about the client's current nutritional status or overall nutritional health.

Choice B

Body mass index (BMI) and serum albumin level is correct. Body mass index (BMI) and serum albumin level are commonly used parameters to assess a client's nutritional status. These measures provide valuable information about the client's weight, muscle mass, and protein status. Let's break down the options:

Choice C

Triceps skin fold and mid-arm circumference is incorrect. These measurements can provide information about the client's body composition and muscle mass. However, they are not as commonly used as BMI and serum albumin level for assessing nutritional status.

Choice D

Weight loss history and body surface area (BSA) is incorrect. Weight loss history is relevant for understanding changes in the client's weight over time, which can indicate potential malnutrition. However, it's not as comprehensive as BMI, which considers both weight and height. Body surface area (BSA) is not typically used to assess nutritional status.

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Which client is at greatest risk for aspiration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a serum sodium level of 155 mEq/L (155 mmol/L). The nurse should encourage the client to make which selection from the lunch menu? Reference Range Sodium [Reference Range: Adult 136 to 145 mEq/L or 136 to 145 mmol/L]

Correct Answer is B

Explanation

The nurse is admitting an older client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

Correct Answer is B

Explanation

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?

Which client is at greatest risk for aspiration?

The charge nurse observes a newly hired nurse who is preparing to insert a nasogastric tube. Which action by the charge nurse takes priority?

The nurse is conducting diet teaching for the family of an older client who has a small reddened area on the coccyx. Based on this finding, which diet should the nurse encourage for this client?

The nurse is developing a food safety educational class for a group of parents. Which type of food is most likely to pose a threat of food poisoning after being stored in a refrigerator at 40°F (4.4°C) or below for more than two days?

A malnourished child is receiving several nutritional supplements. Which statement by the child indicates to the nurse that an adequate amount of Vitamin A is being provided?

During the admission assessment, an older male client who has no teeth tells the nurse that he can not find his dentures at home. His dietary prescription is a regular diet. What diet request should the nurse recommend for this client?

In conducting community health teaching, the nurse plans to describe foods that will help prevent rickets. What food product should the nurse recommend as the best dietary source for preventing rickets?