Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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. A residual of 65 mL 1 hr postprandial
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. Sitting in high-Fowler's position during the feeding
Incorrect. Sitting in high Fowler's position during feeding is actually a preventive measure against aspiration.
C. A history of gastroesophageal reflux disease
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. Receiving a high-osmolarity formula
Incorrect. The osmolarity of the formula might affect tolerance but is not directly related to aspiration risk.
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Full Explanation
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.
Similar Questions
A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take?
A. Measure gastric residual volumes every 4 hr.
Correct. Measuring gastric residual volumes every 4 hours is important to assess gastric emptying and to determine if the client can tolerate the feedings. If residuals are high, it may indicate delayed gastric emptying and the need to adjust the feeding rate.
B. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication.
Incorrect. While flushing the NG tube before and after medications is important to maintain patency, it is typically done with sterile water, not sodium chloride, unless otherwise specified by a protocol. Therefore, this statement may not be fully accurate.
C. Maintain the head of the bed at a 20° angle.
Incorrect. The head of the bed should be elevated to a 30-45° angle to help prevent aspiration during enteral feedings.
D. Advance the rate of the feeding every 2 hr.
Incorrect. The rate of the feeding should be advanced gradually to prevent overloading the client's gastrointestinal tract. This does not involve advancing the rate every 2 hours.
Full Explanation
A. Correct. Measuring gastric residual volumes every 4 hours is important to assess gastric emptying and to determine if the client can tolerate the feedings. If residuals are high, it may indicate delayed gastric emptying and the need to adjust the feeding rate.
B. Incorrect. While flushing the NG tube before and after medications is important to maintain patency, it is typically done with sterile water, not sodium chloride, unless otherwise specified by a protocol. Therefore, this statement may not be fully accurate.
C. Incorrect. The head of the bed should be elevated to a 30-45° angle to help prevent aspiration during enteral feedings.
D. Incorrect. The rate of the feeding should be advanced gradually to prevent overloading the client's gastrointestinal tract. This does not involve advancing the rate every 2 hours.
A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
A. Banana slices
Correct. Banana slices are a soft and easily manageable food that encourages a toddler's independence in eating. They can be easily held by the toddler and self-fed.
B. Hot dog
Incorrect. Hot dogs are a choking hazard due to their shape and texture, which can increase the risk of choking in young children.
C. Grapes
Incorrect. Grapes are also a choking hazard for young children, as they can easily block the airway if not cut into small pieces.
D. Popcorn
Incorrect. Popcorn is a choking hazard due to its size, shape, and hardness. It should be avoided in young children.
Full Explanation
A. Correct. Banana slices are a soft and easily manageable food that encourages a toddler's independence in eating. They can be easily held by the toddler and self-fed.
B. Incorrect. Hot dogs are a choking hazard due to their shape and texture, which can increase the risk of choking in young children.
C. Incorrect. Grapes are also a choking hazard for young children, as they can easily block the airway if not cut into small pieces.
D. Incorrect. Popcorn is a choking hazard due to its size, shape, and hardness. It should be avoided in young children.
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
A. Pale and a 24-hr fluid deficit of 30 mL
Incorrect. A pale appearance and fluid deficit of 30 mL over 24 hours might require intervention but is not as critical as sunken fontanels and dry mucous membranes.
B. Sunken fontanels and dry mucous membranes
Correct. Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.
C. Temperature 38°C (100.4°F) and pulse rate 124/min
Incorrect. A slightly elevated temperature and an increased pulse rate are common responses to infection and fever in infants.
D. Decreased appetite and irritability
Incorrect. Decreased appetite and irritability can be expected in infants with gastroenteritis and are not as concerning as signs of dehydration.
Full Explanation
A. Incorrect. A pale appearance and fluid deficit of 30 mL over 24 hours might require intervention but is not as critical as sunken fontanels and dry mucous membranes.
B. Correct. Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.
C. Incorrect. A slightly elevated temperature and an increased pulse rate are common responses to infection and fever in infants.
D. Incorrect. Decreased appetite and irritability can be expected in infants with gastroenteritis and are not as concerning as signs of dehydration.