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
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Correct Answer is ["A","B","D"]
Explanation
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Correct Answer is B
Explanation
Choice A
The consumption of dairy-based products should be eliminated from the diet. The statement is false Dairy products, especially low-fat or fat-free options, are included in the DASH diet as sources of calcium and other important nutrients. The DASH diet encourages moderation rather than elimination of dairy.
Choice B
The consumption of protein products should come from lean meats, nuts, and dried beans. The statement is correct. The DASH diet encourages including protein sources that are low in saturated fat and high in nutrients. Lean meats, nuts, and dried beans are examples of protein sources that fit this criterion.
Choice C
The consumption of bread products should be gluten-free. The statement is false The DASH diet does not specifically focus on gluten-free options. It emphasizes whole grains as a source of fibre, which is beneficial for heart health.
Choice D
The consumption of fruit and/or vegetables should total between 4 to 6 servings. The statement is false The DASH diet actually encourages a higher intake of fruits and vegetables, aiming for 8 to 10 servings per day. These foods are rich in potassium, magnesium, and fibre, which contribute to the diet's blood pressure-lowering effects.
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