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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A

Opened package of hot dogs is not correct. Hot dogs are processed and often contain preservatives that help extend their shelf life. However, it's still important to follow proper storage guidelines to ensure their safety.

Choice B

Packaged of uncooked lamb chops is not correct. Uncooked meats are generally safe if stored properly. The main concern arises when cooking and handling them, as raw meats can potentially cross-contaminate other foods if proper sanitation measures are not followed.

Choice C

Opened package of deli sliced meat is correct. Among the options provided, an opened package of deli sliced meats (option C) is most likely to pose a threat of food poisoning after being stored in a refrigerator at 40°F (4.4°C) or below for more than two days.

Deli sliced meats are considered a high-risk food for bacterial growth and foodborne illnesses. When meats are sliced and exposed to air, they have a larger surface area, making them more susceptible to bacterial contamination. While the refrigerator temperature of 40°F (4.4°C) helps slow down bacterial growth, it doesn't completely prevent it, especially if the food has been stored for an extended period of time.

Choice D

Ground-up hamburger raw meat is not correct. Similar to uncooked lamb chops, raw ground meat is generally safe when stored properly and handled with care. However, ground meats do have a larger surface area that can allow bacteria to grow more easily, which is why safe cooking practices are important.

A. Explain the benefits of a high fibre diet. B. Confirm that these foods should be avoided. C. Encourage soft foods such as yogurt. D. Suggest that the client also avoid fruit skins.

Correct Answer is B

Explanation

Choice A

Explain the benefits of a high fibre diet is not correct response. While a high fibre diet can indeed be beneficial for individuals with haemorrhoids by promoting regular bowel movements and reducing strain during defecation, the immediate concern here is addressing the client's understanding about avoiding nuts and seeds. This information could be provided as a follow-up after confirming the client's understanding in response to option B.

Choice B

Confirm that these foods should be avoided is the correct response. In this situation, the nurse's first response should be to confirm the client's understanding and provide accurate information about the need to avoid certain foods. Nuts and seeds can be challenging to digest and may lead to irritation and inflammation in individuals with haemorrhoids. Confirming the client's understanding and providing guidance aligns with the nurse's role in patient education and care.

Choice C

Encourage soft foods such as yogurt is not the correct response. Encouraging soft foods like yogurt is a reasonable suggestion for someone with haemorrhoids, as soft foods are generally easier to digest and less likely to cause irritation. However, the client's statement was specifically about avoiding nuts and seeds. While this choice might be relevant, it doesn't directly address the client's statement.

Choice D

Suggest that the client also avoid fruit skins is not the correct response. This option is not directly related to the client's concern about nuts and seeds. Fruit skins generally contain dietary fibre, which can be beneficial for maintaining regular bowel movements. While some individuals might find that certain fruits with tough skins could exacerbate their haemorrhoid symptoms, this advice might be better suited for a separate discussion about dietary choices rather than as a direct response to the client's statement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing a food safety educational class for a group of parents. Which type of food is most likely to pose a threat of food poisoning after being stored in a refrigerator at 40°F (4.4°C) or below for more than two days?

Correct Answer is C

Explanation

A female client with haemorrhoids tells the nurse that she understands the need to avoid eating nuts and seeds to prevent inflammation. How should the nurse respond?

Correct Answer is B

Explanation

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