A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

Report the findings to the healthcare provider.

Review the client's current electrolyte values.

Demonstrate the use of an incentive spirometer.

Connect the tube to low intermittent suction.

Answer and Explanation

The Correct Answer is A

A.   The development of a fever and dyspnea in a client receiving continuous tube feeding could indicate a serious complication, such as aspiration pneumonia, infection, or another significant issue. Reporting these findings to the healthcare provider is crucial for further assessment, diagnosis, and intervention.
B.   While monitoring electrolyte values is important in clients receiving tube feedings, especially if there are concerns about dehydration or imbalances, it is not the immediate priority in this scenario. The client's fever and dyspnea suggest an acute issue that needs prompt attention, and addressing the acute symptoms and reporting them to the healthcare provider takes precedence over reviewing electrolytes.
C.   An incentive spirometer is useful for improving lung function and preventing atelectasis, particularly in postoperative or immobile patients. However, the presence of fever and dyspnea could indicate a more urgent problem such as aspiration or infection, which requires immediate medical evaluation and intervention.
D.   Connecting the tube to low intermittent suction is typically used to decompress the stomach in cases of gastric distension or to prevent aspiration of gastrointestinal contents. However, in the context of the client's new onset of fever and dyspnea, this action does not directly address the potential underlying cause, which could be more serious.

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Correct Answer is B

Explanation

A. Assessing whether the expected outcomes were realistic involves evaluating if the goals set in the plan of care were achievable given the client’s condition, resources, and constraints. While this is an important consideration, it is not the immediate next step after reviewing the expected outcomes.
B. After reviewing the expected outcomes, the next critical step is to gather and analyze current client data. This includes assessing the client’s current condition, symptoms, and responses to interventions. By comparing this data with the expected outcomes, the nurse can determine if the goals are being met, if they need adjustment, or if different interventions are required.
C. Reviewing professional standards of care involves understanding the accepted norms and guidelines for nursing practice. While important, this action typically precedes the direct evaluation of care and is part of ensuring that the care plan was developed and implemented according to professional guidelines.
D. Modifying nursing interventions is an action that might be required if the evaluation shows that the expected outcomes are not being met. However, this action is taken after evaluating the effectiveness of the current interventions by comparing client data with expected outcomes.

A. Apply a debriding agent. B. Apply steri-strips. C. Obtain a wound culture. D. Remove every other suture.

Correct Answer is C

Explanation

A. Debriding agents are used to remove necrotic or non-viable tissue from a wound. While debridement can be necessary if there is evidence of necrotic tissue or eschar, the presence of thick tan exudate alone does not necessarily indicate that debridement is needed.
B. Steri-strips are used to support wound closure and can be applied to wounds with approximated edges. However, in the case of a wound healing by secondary intention (where the edges are not brought together but heal from the inside out), steri-strips are not typically used. This action is not relevant if the wound is healing by secondary intention and if there is a thick exudate present.
C. Obtaining a wound culture is important if there is a suspicion of infection, especially if there is a change in the character of the exudate, increased redness, swelling, or other signs of infection. A thick tan exudate might be indicative of an infection or could be a normal part of the healing process
D. Removing sutures in a wound that is healing by secondary intention is not appropriate as it could disrupt the healing process and potentially lead to complications. Sutures are typically removed when the wound is healing by primary intention and the edges are approximated.

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A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct Answer is B

Explanation

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Correct Answer is C

Explanation

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