A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?
Confirm that bowel sounds are present.
Measure the client's total body weight.
Evaluate the client's ability to swallow.
Observe for signs of fluid volume deficit.
The Correct Answer is A
Choice A reason: Before initiating tube feeding, it is crucial to ensure that the gastrointestinal system is functioning. The presence of bowel sounds indicates peristalsis, which is necessary for the digestion and absorption of the feeding.
Choice B reason: While measuring the client's total body weight is important for overall assessment and monitoring of nutritional status, it is not the most critical assessment before starting tube feeding.
Choice C reason: Evaluating the client's ability to swallow is not relevant in this scenario since the client will be receiving nutrition through a feeding tube due to malnutrition and dehydration.
Choice D reason: Observing for signs of fluid volume deficit is important, but the immediate concern before starting tube feeding is to confirm gastrointestinal activity through the presence of bowel sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Amount (mg) ÷ Concentration (mg/mL) = Volume (mL)
Step 1: The amount of hydromorphone the patient needs is 3 mg. Step 2: The concentration of the hydromorphone solution is 4 mg/mL. Step 3: Substitute the values into the formula: 3 mg ÷ 4 mg/mL.
Step 4: Calculate the volume: 3 ÷ 4 = 0.75 mL. 0.8 rounded to the nearest tenth
Correct Answer is C
Explanation
Choice A reason: Reducing the amount of pressure may not be effective if the pulse is weak or absent; other methods may be needed to assess circulation.
Choice B reason: Documentation is important, but it should be done after all attempts to assess the pulse have been made.
Choice C reason: Using a Doppler stethoscope is a suitable next step when a pulse is not palpable, as it can detect weaker pulses not felt by palpation.
Choice D reason: Palpating the site on the inner side of the ankle below the medial malleolus assesses the posterior tibial pulse, not the dorsalis pedis pulse.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.