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 D
Explanation
Choice A
This is unnecessary and not a standard clinical practice for confirming NGT placement.
Choice B
Withdrawing the NGT and reinsert should not be implemented. If the NGT is in the wrong place, reinserting it without further assessment could worsen the situation. The nurse should not reinsert the NGT until the correct placement is confirmed.
Choice C
Connecting the NGT to wall suction should not be implemented. Connecting the NGT to wall suction without verifying its placement could cause harm, especially if the tube is in the respiratory tract.
Choice D
This is the most evidence-based bedside method to confirm placement after the initial X-ray. Gastric aspirate typically has a pH of 5.0 or less. If the pH is higher (e.g., >6.0), it may indicate that the tube is in the lungs or the small intestine.

Correct Answer is D
Explanation
Choice A
Sweaty palms are incorrect. Sweaty palms could be a normal response to physical activity and might not necessarily indicate a significant underlying issue.
Choice B
Bunions are incorrect. While bunions can cause discomfort, they might not be directly related to overall health, especially in comparison to fatigue.
Choice C
Dry skin is incorrect. Dry skin could be related to various factors, including environmental conditions or skincare habits. While it's worth addressing, it might not be as immediately concerning as unexplained fatigue.
Choice D
Fatigue is correct. For a professional dancer, fatigue should be an issue that alerts the nurse to perform further assessment. While all of the options can provide information about the client's health, fatigue in a professional dancer could be indicative of various underlying issues that may affect their overall well-being and performance.
Fatigue in a dancer might result from factors such as inadequate nutrition, overtraining, insufficient rest, or underlying medical conditions. It's important for the nurse to explore further to understand the potential causes of the fatigue and address them appropriately.
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