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?

Decrease the rate of the feeding by half.

Observe for an allergic reaction to the formula.

Hang a new bag of the enteral formula.

Stop the tube feeding and assess the client.

Answer and Explanation

The Correct Answer is D

A.   Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B.   While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C.   Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D.   Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

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Correct Answer is B

Explanation

A. Applying cornstarch or other powders to moist skin can exacerbate dryness and irritation, as powders can absorb moisture but also contribute to a dry skin environment. In general, powders are not recommended for use on already dry or irritated skin, especially for older adults, as they can lead to further skin issues or contribute to fungal infections.
B. Gently applying lotion or moisturizer to the skin after bathing is the most appropriate action. Moisturizers help to rehydrate and lock in moisture, reducing the risk of dry, itchy skin. Applying lotion to damp skin (immediately after bathing) is particularly effective as it helps to seal in the moisture.
C. Adding bath oil to the bath water can be beneficial for moisturizing the skin, as it helps to create a barrier that prevents moisture loss. However, for the client’s specific request about post-bath relief, adding oil to the bath water does not address the immediate need for skin care after bathing.
D. Liquid soap can be gentler on the skin compared to bar soap, which can be drying, especially if it contains harsh ingredients. However, switching from bar soap to liquid soap is a preventive measure and does not provide immediate relief for already dry and itchy skin.

A. C-reactive protein level. B. Culture for sensitive organisms. C. Serum albumin. D. Serum blood glucose (BG) level.

Correct Answer is B

Explanation

A. CRP is an acute-phase protein produced by the liver in response to inflammation. Elevated CRP levels indicate systemic inflammation or infection. Measuring the CRP level can help confirm the presence of an inflammatory process, such as infection, and monitor the severity of inflammation. However, while useful, CRP alone might not provide the complete picture needed for specific wound management.
B. Culturing the wound for sensitive organisms is crucial when an infection is suspected. This test will identify the specific bacteria or other pathogens causing the infection and determine their sensitivity to various antibiotics. This information is essential for choosing the appropriate treatment to address the infection effectively.
C. Serum albumin levels provide information about the client’s nutritional status and can reflect protein malnutrition. Low serum albumin levels can indicate poor wound healing due to inadequate protein levels, which affects tissue repair. While serum albumin is important for understanding overall nutritional status, it does not directly diagnose or confirm infection.
D. Blood glucose levels are important to monitor, especially in diabetic patients, as high blood glucose can impair wound healing and increase the risk of infections. However, blood glucose levels are more related to the client's ability to heal rather than directly identifying or managing an infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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