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 A
Explanation
The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.
Choice B is wrong because the task is within the AP’s range of function to perform.
This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.
Choice C is wrong because the task can be performed in the same manner for most clients.
This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.
Choice D is wrong because the task requires a specific sequence of steps.
This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.
Correct Answer is A
Explanation
The nurse should notify the provider because this value is lower than the normal range of 150,000 to 450,000 platelets per microliter of blood. A low platelet count can indicate a risk of bleeding or a condition such as thrombocytopenia or disseminated intravascular coagulation (DIC).
Choice B is wrong because WBC count 9,800/mm³ is within the normal range of 4,500 to 11,000 cells per microliter of blood.
Choice C is wrong because Hgb 13 mg/dL is within the normal range of 12 to 16 mg/dL for females and 14 to 18 mg/dL for males.
Choice D is wrong because Hct 42% is within the normal range of 37% to 47% for females and 42% to 52% for males.
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