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?

Rationale: A. High-osmolarity formulas can cause gastrointestinal side effects such as diarrhea, cramping, and fluid shifts, but they are not a primary risk factor for aspiration. Aspiration risk is more closely related to gastric emptying, positioning, and neurologic or esophageal conditions. B. A gastric residual of 65 mL is generally considered acceptable in many adult feeding protocols (thresholds often range from 100–250 mL depending on policy). It may require monitoring but does not directly indicate a high aspiration risk on its own. C. High-Fowler’s position (30–45 degrees or higher) actually reduces the risk of aspiration during enteral feeding by promoting gastric emptying and preventing reflux. It is a protective measure, not a risk factor. D. Gastroesophageal reflux disease (GERD) increases the risk of aspiration because gastric contents can flow backward into the esophagus and potentially enter the airway, especially in clients receiving enteral feedings. This risk is heightened in clients with impaired swallowing, decreased consciousness, or poor lower esophageal sphincter function.