NCLEX · Basic Care and Comfort

Which finding in a client receiving enteral feedings via nasogastric tube indicates possible aspiration?

Correct answer

New-onset cough, increased respiratory rate, decreased oxygen saturation, fever, abnormal lung sounds

  1. A New-onset cough, increased respiratory rate, decreased oxygen saturation, fever, abnormal lung sounds
  2. B Decreased urinary output
  3. C Increased appetite
  4. D Normal bowel sounds

Why this is the answer

Aspiration is a major risk of enteral feeding. Signs of aspiration: new-onset cough during or after feeding; increased respiratory rate; decreased oxygen saturation; fever (often delayed); abnormal lung sounds (crackles, decreased breath sounds, especially in dependent areas); change in mental status. Prevention strategies: (1) Verify tube placement before each feeding (radiographic confirmation initially, then mark position and check for migration; pH testing of aspirate is also used — gastric pH should be acidic, less than 5); (2) Keep the head of bed elevated at least 30-45 degrees during feeding and for 30-60 minutes after; (3) Check residual volume per facility policy (typically before each intermittent feeding or every 4 hours for continuous feedings); withhold and notify provider if high residuals (definitions vary, often >250 mL or per provider order); (4) Use small bowel placement (post-pyloric tube) for high-risk clients; (5) Assess swallow function before resuming oral intake. Suspected aspiration: stop the feeding, suction airway, elevate head, assess vital signs, notify provider, anticipate chest x-ray and possibly antibiotics.
Source: NCLEX-RN, Basic Care — Enteral Feeding Safety

Practice more questions

This question is from our NCLEX Practice Tests practice test. Take the full practice test to test your knowledge across all Basic Care and Comfort and other topics.

Take the RN: Physiological Integrity practice test →

About this topic: Basic Care and Comfort

Basic care and comfort questions cover mobility, positioning, nutrition, elimination, hygiene, sleep and comfort measures, and the assistive devices and complementary therapies that support them. This is one of 6 RN: Physiological Integrity questions on basic care and comfort, each with a full explanation on a single study page.

New to this exam? Our NCLEX exam guide explains the format, scoring, and how to prepare.

Related questions

State-specific guides

Need information for your state? Our state guides cover local requirements, fees, and what to expect on exam day.