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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Orthopnea is a condition where a person has difficulty breathing when lying flat and may require sitting or standing to breathe more easily. While documenting orthopnea is important for the medical record and understanding the client’s condition, it is not the immediate priority in addressing acute breathing difficulty.
B. Elevating the head of the bed is an immediate and effective action to help alleviate breathing difficulty. This position helps improve respiratory mechanics by allowing the diaphragm to move more freely and reducing pressure on the lungs.
C. Using a pulse oximeter to measure oxygen saturation is important for assessing the client’s oxygen levels and determining the need for supplemental oxygen. However, this action is secondary to immediately addressing the position that is causing difficulty.
D. Assessing vital signs is important for a comprehensive evaluation of the client’s overall condition and to identify any critical changes in health status. However, in the case of immediate breathing difficulty, it is more urgent to take actions that directly address the breathing issue before performing a thorough assessment.

A. Position the package of gauze pads on a sterile field. B. Discard the open bottle of solution before continuing. C. Recap the solution and apply a pair of sterile gloves. D. Obtain all new supplies and start the procedure again.

Correct Answer is A

Explanation

A. Positioning the package of gauze pads on a sterile field is an appropriate action to maintain sterility and ensure that all items used in the procedure remain uncontaminated. However, this step should be considered only if the solution was poured correctly and the sterility of the gauze pads and solution has been maintained.
B. Discarding the open bottle of solution is not necessary unless it has been contaminated. If the solution is still sterile and has not been contaminated (e.g., by touching non-sterile surfaces), there is no need to discard it. The focus should be on ensuring that the solution and all other items remain sterile.
C. Recapping the solution is not recommended because it can lead to contamination. Instead, the solution should be left open or covered with a sterile cap, if provided. Applying sterile gloves is essential for maintaining sterility during the dressing change procedure, but this should be done after ensuring that all supplies and steps are in order.
D. This action would be necessary only if there was a contamination issue or if the sterility of the supplies or solution was compromised. If the sterile technique was not followed properly or there was a risk of contamination, starting the procedure again with new supplies would be appropriate.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?

Correct Answer is B

Explanation

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

Correct Answer is A

Explanation

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

An older female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client?

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?