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 B
Explanation
Moist heat can help reduce pain and stiffness in the joints by increasing blood flow and relaxing the muscles. Moist heat can be applied using warm compresses, heating pads, or warm baths.
Choice A is wrong because using a recliner when sitting for long periods can increase pressure on the knees and decrease circulation. A better option is to use a straight-backed chair with a footstool.
Choice C is wrong because sleeping on a soft mattress can cause poor alignment of the spine and joints, which can worsen pain and mobility. A firm mattress is recommended for clients with osteoarthritis.
Choice D is wrong because placing large pillows under the knees when lying in bed can limit the range of motion of the knees and cause contractures. A small pillow under the knees can provide some support and comfort, but it should not be too large or too high.
Correct Answer is D
Explanation
The nurse should instruct the client to avoid bananas because they are one of the foods that can cause a cross-reaction with latex allergy. This means that people who are allergic to latex may also have an allergic reaction to bananas because they contain similar proteins.
Choice A is wrong because wheat is not a latex cross-reactive food.
Choice B is wrong because strawberries are a low or undetermined cross- reactive food.
Choice C is wrong because peanuts are a low or undetermined cross-reactive food.
Some other foods that the nurse should instruct the client to avoid are avocado, kiwi, chestnut, papaya, and potato. These foods have a high or moderate association with latex cross-reactions. The client should also be careful with other fruits and vegetables that may contain similar proteins to latex.
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