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 C

Explanation

A. This description is more characteristic of a Stage 3 or Stage 4 pressure injury. Stage 3 pressure injuries involve full-thickness skin loss and may expose subcutaneous tissue, and Stage 4 involves extensive damage with possible exposure of muscle, bone, or tendon. Sloughing (a type of necrotic tissue) is not typical of Stage 2 pressure injuries.
B. This description is more indicative of a Stage 1 pressure injury. Stage 1 injuries are characterized by non-blanchable erythema of intact skin, and pain or discomfort in the affected area is common. Stage 1 does not involve the loss of skin integrity, so it would not be the appearance of a Stage 2 injury.
C. This description accurately matches the appearance of a Stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness loss of skin, which may present as a shallow open ulcer with a red or pink wound bed. It does not extend through the entire thickness of the skin.
D. This description aligns with Stage 3 or Stage 4 pressure injuries, which involve full-thickness skin loss with possible necrotic tissue and deep pockets of infection. These stages involve significant tissue damage beyond what is seen in Stage 2 injuries.

A. Egg whites, toast, and coffee. B. Bran muffin, mixed fruit, and orange juice. C. Granola bar and grapefruit juice. D. Bagel with jelly and skim milk.

Correct Answer is B

Explanation

A. While this breakfast is healthy and nutritious, it does not contain significant amounts of calcium or vitamin D, which are essential for bone health.
B. Bran muffins, mixed fruit, and orange juice are all good sources of calcium and vitamin D, two essential nutrients for bone health. A diet rich in calcium and vitamin D is recommended for individuals with osteoporosis to help strengthen bones and reduce the risk of fractures.
C. While granola bars and grapefruit juice can be healthy, they may not provide enough calcium and vitamin D to meet the nutritional needs of a client with osteoporosis.
D. While skim milk is a good source of calcium, the bagel and jelly do not provide significant amounts of calcium or vitamin D.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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