A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

The nurse administers the feeding through a syringe barrel by gravity.

The nurse allows the client to rest in a supine position during feeding.

The nurse irrigates the NG tube with tap water after feeding.

The nurse initiates the feeding after aspirating 50 mL of gastric residual.

Answer and Explanation

The Correct Answer is B

A. The nurse administers the feeding through a syringe barrel by gravity.
This is an appropriate method for administering intermittent tube feedings. Gravity feeding with a syringe allows for controlled delivery of the feeding solution.

B. The nurse allows the client to rest in a supine position during feeding.
Feeding a client in a supine position is generally acceptable, especially if the client is comfortable and doesn't experience complications. However, if there are specific contraindications or concerns for aspiration, the nurse should follow the prescribed position guidelines.

C. The nurse irrigates the NG tube with tap water after feeding.
Using tap water to irrigate an NG tube is not recommended, as it may lead to complications such as electrolyte imbalances. Sterile or distilled water should be used for irrigation.

D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
This is an appropriate action. Aspirating gastric residual before initiating a feeding helps assess the presence of gastric contents, ensuring that the client is ready to receive the feeding. However, specific institutional policies may dictate the threshold for gastric residual volume that requires intervention.

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Correct Answer is C

Explanation

A. Metoprolol 50 mg PO daily:
This is a beta-blocker that helps lower blood pressure and heart rate. While it may be part of managing heart failure, it is not the immediate priority in a client presenting with signs of fluid overload and congestion.

B. Maintain accurate intake and output records:
Monitoring intake and output is important in managing fluid balance.
However, in this situation, the priority is to address the existing fluid overload promptly.

C. Furosemide (Lasix) 40 mg push:
Furosemide is a loop diuretic that promotes the excretion of excess fluid. Administering it "push" implies a more rapid onset of action, making it suitable for addressing acute fluid overload.

D. Encourage fluid intake, more than 2000 mL/day:
In the context of fluid overload, encouraging additional fluid intake is contraindicated. The focus should be on removing excess fluid with diuretic therapy rather than promoting more intake.

A. The patient uses crutches with a swing-to gait. B. The patient sits straight up on the edge of the bed. C. The patient bends over the sink while brushing teeth. D. The patient leans over to pull on shoes and socks.

Correct Answer is ["C","D"]

Explanation

A. The patient uses crutches with a swing-to gait.
This action doesn't necessarily indicate a concern after hip arthroplasty. However, the nurse might want to assess the patient's gait and the use of crutches to ensure the proper technique is being employed and that the patient feels comfortable and stable.

B. The patient sits straight up on the edge of the bed.
Sitting straight up on the edge of the bed may not be suitable immediately after hip arthroplasty, especially with the posterior approach. The nurse should assess the patient's ability to sit upright without putting excessive pressure or strain on the surgical site.

C. The patient bends over the sink while brushing teeth.
Bending over can put stress on the surgical site and should be avoided during the initial recovery period after hip arthroplasty. This action might strain the incision and affect the healing process.

D. The patient leans over to pull on shoes and socks.
Similar to bending over the sink, leaning over to put on shoes and socks can strain the hip joint and surgical site. This movement could potentially put stress on the incision and hinder the healing process.

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A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["C","D"]

Explanation

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