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
The indirect Coombs test is used to detect antibodies against foreign red blood cells in the maternal serum. This test can help identify maternal-fetal blood incompatibility, which can cause hemolytic disease of the newborn.
Choice A is wrong because homocysteine is a type of amino acid and is not related to blood compatibility.
Choice C is incorrect because erythropoietin is a hormone that regulates red blood cell production and is not a specific test for detecting maternal-fetal blood incompatibility.
Choice D is not the correct answer as aPTT (activated partial thromboplastin time) is a test used to evaluate blood clotting factors and is not directly related to monitoring maternal-fetal blood incompatibility.
Correct Answer is C
Explanation
Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.
Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.
Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.
Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today