A charge nurse is observing a newly licensed nurse administer an enteral feeding to a client who has an established gastrostomy tube.
Which of the following actions by the newly licensed nurse indicates that the charge nurse should intervene?
The nurse checks the volume of the aspirate.
The nurse checks the pH of the aspirate.
The nurse administers 15 mL of water before administering the feeding.
The nurse adds food coloring to the tube feeding.
The Correct Answer is D
This action indicates that the charge nurse should intervene because adding food coloring to the tube feeding is not recommended and can cause adverse effects such as aspiration, diarrhea, and allergic reactions.
Choice A is wrong because checking the volume of the aspirate is a correct action to assess gastric residual volume and prevent complications such as nausea, vomiting, and aspiration.
Choice B is wrong because checking the pH of the aspirate is a correct action to verify the placement of the NG tube and prevent accidental administration of enteral feeding into the lungs.
Choice C is wrong because administering 15 mL of water before administering the feeding is a correct action to flush the NG tube and prevent clogging.
Normal ranges for gastric residual volume are less than 250 mL for adults and less than 5 mL/kg for children. Normal ranges for pH of gastric aspirate are less than 5.5 for adults and less than 4 for children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
BMI 32.2.
A high body mass index (BMI) is a major risk factor for type 2 diabetes mellitus, as it indicates overweight or obesity.
Overweight or obesity can cause insulin resistance, which means the body cells do not respond well to insulin and cannot take up glucose from the blood. This leads to high blood sugar levels and diabetes.
Choice A is wrong because history of exercise-induced asthma is not a risk factor for type 2 diabetes mellitus.
Asthma is a respiratory condition that causes inflammation and narrowing of the airways, but it does not affect the metabolism of glucose or insulin.
Choice B is wrong because age 35 years is not a risk factor for type 2 diabetes mellitus.
Although the risk of diabetes increases with age, especially after 45 years, it can also occur in younger people.
Age alone is not enough to cause diabetes.
Choice C is wrong because history of mumps is not a risk factor for type 2 diabetes mellitus.
Mumps is a viral infection that affects the salivary glands, but it does not damage the pancreas or impair insulin production.
Some other risk factors for type 2 diabetes mellitus are family history, race or ethnicity, physical inactivity, prediabetes, gestational diabetes, polycystic ovarian syndrome, and smoking.
Correct Answer is C
Explanation
The nurse should explain that the injection is administered in order to prevent vitamin K deficiency bleeding (VKDB) in the newborn. Vitamin K is needed for blood clotting, but newborn babies have very low levels of vitamin K in their bodies at birth because only small amounts of the vitamin pass through the placenta and breast milk. VKDB can cause life-threatening bleeding in various parts of the body, such as the brain, intestines, or skin. VKDB can be classified into early-onset, classic, or late- onset depending on the time of presentation after birth. The most effective way to prevent VKDB is to give a single intramuscular dose of 0.5 to 1 mg of vitamin K to all newborn infants within 6 hours of birth.
Choice A is wrong because sepsis is not caused by vitamin K deficiency, but by bacterial infection.
Choice B is wrong because tachypnea is not caused by vitamin K deficiency, but by respiratory distress or other conditions.
Choice D is wrong because jaundice is not caused by vitamin K deficiency, but by high levels of bilirubin in the blood.
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