This question tests understanding of enteral feeding and aspiration precautions. Priority nursing actions include elevating the head of the bed to 30-45 degrees and monitoring for reflux symptoms in at-risk clients. Elevating the head of the bed to 30-45 degrees and keeping it elevated during and after feeding per policy is the best choice because it reduces gastroesophageal reflux and aspiration risk in a client with drooling, weak cough, and low positioning. Adding fiber addresses constipation, not aspiration; irrigating with 120 mL water checks patency but not position; changing to higher-calorie formula affects nutrition, not immediate risk. The decision-making principle is to address positional factors that prevent regurgitation in clients with neurological impairments. Aspiration precautions include maintaining elevation to promote gastric emptying and reduce reflux. A transferable strategy is to assess and correct positioning before and during feedings, especially in clients with impaired swallow reflexes, to prevent aspiration in enteral nutrition.

This question tests understanding of enteral feeding and aspiration precautions. Priority nursing actions include re-verifying tube placement after any potential displacement and ensuring proper positioning. The tube being retaped after coughing with no re-verification documented indicates increased risk of aspiration because coughing may dislodge the tube, leading to misplacement and pulmonary feeding. Respiratory rate 18/min is normal; temperature 37.0°C is normal; capillary refill less than 2 seconds indicates perfusion but not aspiration risk. The decision-making principle is to recognize signs of potential tube displacement as a critical risk for aspiration. Aspiration precautions mandate documentation and verification after events like coughing. A transferable strategy is to routinely check and document tube markings and re-verify placement after any incident that could cause migration to prevent aspiration in clients on enteral nutrition.

This question tests understanding of enteral feeding and aspiration precautions. Priority nursing actions include recognizing high residuals as a risk for regurgitation. Gastric residual volume 300 mL with abdominal distension indicates increased risk of aspiration because it suggests delayed emptying, promoting reflux in a coughing client. Head of bed at 40 degrees is protective; temperature 36.8°C is normal; glucose 128 mg/dL is normal. The decision-making principle is to link high residuals with overflow aspiration potential. Aspiration precautions involve holding feedings for elevated residuals. A transferable strategy is to check residuals pre-feeding and hold if high to prevent regurgitation and aspiration in enteral nutrition clients.

This question tests understanding of enteral feeding and aspiration precautions. Priority nursing actions include questioning orders that compromise positioning in at-risk clients. Administering bolus feedings while the client is lying flat to promote comfort should be questioned because flat positioning increases reflux and aspiration risk in a drowsy, nauseous client with history. Maintaining elevation is correct; checking placement is essential; providing oral care reduces risk. The decision-making principle is to oppose orders ignoring elevation standards. Aspiration precautions forbid supine feedings. A transferable strategy is to evaluate orders for alignment with aspiration prevention guidelines to ensure safe enteral nutrition delivery.

This question tests understanding of enteral feeding and aspiration precautions. Priority nursing actions include identifying respiratory symptoms as aspiration risks. Gurgling respirations requiring frequent throat clearing indicate increased risk of aspiration because they suggest secretions or reflux entering the airway in a lethargic client. Gastric residual 90 mL is acceptable; head of bed at 45 degrees is protective; heart rate 76/min is normal. The decision-making principle is to recognize gurgling as a sign of potential silent aspiration. Aspiration precautions involve monitoring for subtle respiratory changes. A transferable strategy is to assess for gurgling or throat clearing and provide suctioning or positioning adjustments to prevent aspiration in enteral nutrition clients.

This question tests understanding of enteral feeding and aspiration precautions. Priority nursing actions include verifying tube placement before initiating feedings and elevating the head of the bed to at least 30 degrees. Verifying tube placement according to facility policy before initiating feeding is the best choice because it ensures the tube is in the stomach, preventing accidental pulmonary administration and aspiration, especially in a client with decreased consciousness and reflux history. Beginning the feeding slowly addresses tolerance but not placement; flushing with sterile water checks patency but not position; obtaining a stool sample is unrelated to immediate aspiration prevention. The decision-making principle is to confirm tube placement as the first step before any administration to avoid misplacement-related aspiration. Aspiration precautions require evidence-based methods like pH testing or x-ray confirmation for tube verification. A transferable strategy is to always document and re-verify tube placement after insertion or any potential displacement to safeguard against aspiration in enteral nutrition clients.

This question tests understanding of enteral feeding and aspiration precautions. Priority nursing actions include managing oral secretions to prevent aspiration in sedated clients. Frequent pooling of oral secretions in a sedated client indicates increased risk of aspiration because sedation impairs swallow, allowing secretions to enter the airway. Gastric residual 30 mL is low and safe; oxygen saturation 98% is normal; head of bed at 30 degrees is protective but does not address secretions. The decision-making principle is to identify unmanaged secretions as a silent aspiration risk. Aspiration precautions involve frequent suctioning in compromised clients. A transferable strategy is to assess and clear oral secretions regularly, especially in sedated individuals, to prevent aspiration during enteral nutrition.

This question tests understanding of enteral feeding and aspiration precautions. Priority nursing actions include stopping the feeding immediately if aspiration is suspected, elevating the head of the bed to 30-45 degrees, and assessing airway and breathing. Stopping the feeding and elevating the head of the bed to 30-45 degrees is the best choice because it prevents further aspiration by reducing reflux and promoting airway clearance in a client showing signs of aspiration like coughing, crackles, and decreased oxygen saturation. Requesting a swallow evaluation is important but not immediate; auscultating bowel sounds addresses gastrointestinal function, not aspiration; delegating suction setup while continuing feeding increases risk by not stopping the feeding. The decision-making principle is to prioritize airway protection and immediate interventions to mitigate aspiration risk during signs of respiratory distress. Aspiration precautions emphasize rapid response to symptoms like coughing or oxygen desaturation by halting feeding and optimizing positioning. A transferable strategy is to routinely monitor for early signs of aspiration, such as changes in lung sounds or oxygen levels, and maintain head-of-bed elevation to prevent complications in clients on enteral nutrition.

This question tests understanding of enteral feeding and aspiration precautions. Priority nursing actions include stopping feedings and ensuring elevation during acute gagging or coughing. Stopping the feeding and maintaining the client in an elevated position while maintaining airway patency is the best choice because it addresses immediate aspiration by halting the source and supporting breathing. Increasing rate heightens risk; checking residuals delays; delegating while continuing is unsafe. The decision-making principle is to prioritize airway management over continuation during distress. Aspiration precautions require immediate cessation and assessment. A transferable strategy is to respond to gagging or desaturation by stopping feedings and elevating position to prevent aspiration in enteral nutrition clients.

This question tests understanding of enteral feeding and aspiration precautions. Priority nursing actions include holding feedings for active nausea or vomiting to avoid aspiration. Holding the feeding and assessing for ongoing nausea/vomiting while maintaining head-of-bed elevation is the best choice because starting amid severe nausea risks regurgitation and aspiration. Starting at ordered rate ignores symptoms; delegating to UAP is inappropriate; offering ice chips may worsen nausea. The decision-making principle is to delay initiation until GI stability to prevent complications. Aspiration precautions prioritize symptom resolution. A transferable strategy is to assess for nausea/vomiting pre-feeding and hold if present to prevent aspiration in enteral nutrition clients.