A client is receiving a continuous gastric tube feeding at 80 mL/hour. The nurse records the client's gastric residual volume as 325 mL during each of two consecutive hourly measurements. What assessment should the nurse complete before contacting the healthcare provider?
Observe for abdominal distention,
Calculate 24-hour caloric intake.
Measure the urinary output.
Check for body weight changes.
The Correct Answer is A
Choice A
Observing for abdominal distention is recommended. Gastric residual volume (GRV) is the amount of formula or food remaining in the stomach after a feeding through a gastric tube. A GRV of 325 mL is relatively high, and it's important to assess the client for signs of potential complications before contacting the healthcare provider. Observe for signs of abdominal distention, which could indicate that the stomach is not adequately emptying or that the feeding is not being tolerated well.
Choice B
Calculating 24-hour caloric intake is not recommended: While monitoring caloric intake is important for overall nutritional assessment, it does not address the immediate concern of a high GRV and the potential need for adjustment of the feeding rate or management.
Choice C
Measuring urinary output is not recommended: Urinary output is important to monitor for fluid balance, but it may not be directly related to the elevated GRV.
Choice D
Checking for body weight changes is not recommended: Monitoring body weight is essential for assessing nutritional status, but it may not provide immediate insights into the impact of the elevated GRV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
1 whole-wheat tortilla, 4 oz chicken breast, 4 of an avocados, 1/4 cup of salsa
1030
1 cup coffee, 2 tbsp half and half, 1 small apple, 1 tbsp almond butter
1200
1 cup spinach, 4 oz ground turkey with taco seasoning. 1/4 cup cheddar cheese, 2 bananas
1500
6 cashews
1900
1 cup regular soda, 6 oz white fish, 1/2 white potato, 2 tbsp butter, 1⁄2 cup green beans
2200
1⁄2 cup fat-free yogurt, 1/4 cup blueberries
Correct Answer is ["B","D","E"]
Explanation
Choice A
Pickles, blackberries, seeds are not appropriate. None of these foods are particularly high in calcium. Pickles and blackberries are not significant sources of calcium, and while some seeds contain calcium, they are not among the best sources.
Choice B
Buttermilk, spinach, milk: These foods are good sources of dietary calcium is appropriate. Milk and buttermilk are commonly consumed dairy products that contain calcium. Spinach, while not as high in calcium as dairy products, still contributes to calcium intake.
Choice C
Pickled olives, spam, nuts are not appropriate. These foods are not known for being high in calcium. Additionally, some foods like pickled olives and spam may have high sodium content, which can affect calcium balance.
Choice D
Fresh meats, fresh turkey, fresh chicken is appropriate. Fresh meats, such as turkey and chicken, provide some calcium, although not as much as dairy products. They also contribute to overall nutritional intake.
Choice E
Cheese spread, processed cheese, cheese is appropriate. Dairy products like cheese, especially processed cheese and cheese spread, are good sources of calcium. They can be effective in increasing calcium intake to address hypocalcaemia.
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