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.

Answer and Explanation

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.

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Correct Answer is ["D","E"]

Explanation

Choice A reason: Oatmeal, cream of wheat, and pureed liquids are not clear liquids and are not appropriate for a clear liquid diet.
Choice B reason: Pureed beans, liquid protein supplements, and milkshakes are not considered clear liquids and should not be included in a clear liquid diet.
Choice C reason: Pureed carrots, creamed soup, and ice cream are not clear liquids because they are not transparent and cannot be consumed on a clear liquid diet.
Choice D reason: Carbonated drinks, gelatin, and broth are considered clear liquids because they are transparent and can be consumed on a clear liquid diet.
Choice E reason: Water, tea without milk or cream, and ice chips are clear liquids and are appropriate for a clear liquid diet.

A. Confer with the physical therapist for correct crutch size. B. Ask the client to sit down while the crutch length is adjusted. C. Assess the client for signs of diminished circulation in the hands. D. Proceed with teaching the client how to walk with the crutches.

Correct Answer is D

Explanation

The correct answer is choiced. Proceed with teaching the client how to walk with the crutches.

Choice A rationale:

Confer with the physical therapist for correct crutch size. This is unnecessary because the crutches are already correctly fitted.A space of three finger widths between the top of the crutch and the client’s axilla is appropriate to prevent pressure on the axilla and potential nerve damage.

Choice B rationale:

Ask the client to sit down while the crutch length is adjusted. This action is not needed since the crutches are already properly adjusted.Adjusting the crutch length further could lead to improper fitting, which might cause discomfort or injury.

Choice C rationale:

Assess the client for signs of diminished circulation in the hands. While assessing circulation is important, it is not directly related to the fitting of the crutches.Proper crutch fitting focuses on ensuring there is no pressure on the axilla and that the client can use the crutches comfortably.

Choice D rationale:

Proceed with teaching the client how to walk with the crutches. This is the correct action because the crutches are already properly fitted.The nurse should now focus on educating the client on the correct use of the crutches to ensure safe and effective mobility.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.

Correct Answer is ["D","E"]

Explanation

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Correct Answer is D

Explanation

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (K+) 3.5 to 5 mEq/L (3.5 to 5 mmol/L)

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