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 B

Explanation

Choice A reason: While teaching alternative ways to manage pain is important, it does not address the immediate issue of the client not taking the medication as prescribed.

Choice B reason: The client should be instructed to take the medication as prescribed to maintain consistent pain control and prevent breakthrough pain.

Choice C reason: Advising the client to take the medication only with severe pain is contrary to the prescribed regimen and could lead to inadequate pain management.

Choice D reason: It is important to discuss the risks of long-term medication use, but the priority is to ensure that the client understands the importance of taking the medication as prescribed for effective pain management.

A. Secure an allergy bracelet around the client's wrist. B. Notify the dietary department of the client's fruit allergy. C. Send a list of medication allergies to the pharmacy. D. Place a latex-free supply cart outside the client's room.

Correct Answer is A

Explanation

Choice A reason: An allergy bracelet provides immediate visual notification of the client's allergies to all healthcare personnel, which is crucial for preventing allergic reactions.

Choice B reason: Notifying the dietary department is important, but it does not have the same immediate impact on client safety as an allergy bracelet.

Choice C reason: Sending a list of medication allergies to the pharmacy is a necessary step, but it is secondary to providing immediate identification of the client's allergies.

Choice D reason: Placing a latex-free supply cart outside the room is a proactive measure to prevent exposure to latex, but the first step should be to ensure that the client's allergies are clearly identified for all staff.

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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

An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?

Correct Answer is B

Explanation

During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

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A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

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