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 C
Explanation
Choice A
Beef broth should not be omitted. Generally, clear broths like beef broth are lower in fat and may be a better choice for someone with cholelithiasis compared to creamy or fatty foods.
Choice B
Ketchup should not be omitted. Ketchup is not typically high in fat and may not be a significant concern for someone with cholelithiasis.
Choice C
Ice cream should be omitted. Cholelithiasis refers to the presence of gallstones in the gallbladder. Gallstones can form from substances in the bile, and certain foods can trigger symptoms in individuals with gallbladder issues. One of the common triggers is high-fat foods, which can cause the gallbladder to contract and potentially lead to pain or discomfort.
Choice D
Bread should not be omitted. While bread contains some fat, it's not as high in fat as ice cream. The focus for individuals with cholelithiasis is often on high-fat foods rather than moderate-fat foods like bread.

Correct Answer is C
Explanation
Choice A
Following low carbohydrate diet with low glycaemic index foods is incorrect. This recommendation is not specifically related to the management of glomerulonephritis. While managing carbohydrate intake might be relevant for individuals with diabetes, it's not the primary focus for someone with kidney inflammation.
Choice B
Eating a high protein diet three times a day is incorrect: While protein is important for overall health and recovery, a high protein diet might not be the best recommendation for someone with compromised kidney function. Excessive protein intake could potentially put additional strain on the kidneys.
Choice C
Avoiding foods high in potassium is correct. Examples of foods high in potassium that the client should be cautious about include bananas, oranges, potatoes, tomatoes, spinach, and other fruits and vegetables. Glomerulonephritis is a condition involving inflammation of the glomeruli in the kidneys, which can affect kidney function and the regulation of electrolytes, including potassium. In glomerulonephritis, the kidneys might have difficulty filtering and excreting excess potassium, leading to a potential build-up of potassium in the blood (hyperkalaemia).
Choice D
Restricting sodium rich foods and excessive oral fluids is incorrect. This recommendation aligns more closely with managing fluid retention and blood pressure, which can be relevant for individuals with kidney issues. However, the primary concern in glomerulonephritis is often potassium balance, making the recommendation to avoid high potassium foods more pertinent.

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