A nurse is administering an intermittent enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take?
Replace the NG tube.
Lower the head of the bed to 15°.
Slow the rate of formula instillation.
Chill and readminister the formula.
The Correct Answer is C
A. Replace the NG tube.: There is no indication that the NG tube is malfunctioning or misplaced in this case. The cramping and nausea are more likely related to the feeding itself, not the tube.
B. Lower the head of the bed to 15°.: Lowering the head of the bed would increase the risk of aspiration. The head of the bed should be elevated during enteral feeding to reduce this risk.
C. Slow the rate of formula instillation.: Abdominal cramping and nausea during enteral feeding can occur if the feeding rate is too fast. Slowing the rate allows the stomach to better tolerate the formula and can alleviate symptoms.
D. Chill and readminister the formula.: The temperature of the formula should not cause the cramping or nausea. Feeding should be administered at room temperature or as directed by protocol, and re-chilling it is unlikely to help with the symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tachypnea: Tachypnea (rapid breathing) is not a typical effect of magnesium sulfate. Magnesium sulfate is more likely to cause respiratory depression, especially at higher doses, rather than increasing the rate of breathing.
B. Tachycardia: Tachycardia (rapid heart rate). is not a common finding with magnesium sulfate administration. Magnesium sulfate typically causes a decrease in heart rate (bradycardia. and may also contribute to hypotension.
C. Hypotension: Hypotension is the correct finding. Magnesium sulfate has a vasodilatory effect, which can lead to a drop in blood pressure. This is a well-known side effect of magnesium sulfate, particularly when administered intravenously.
D. Hyperthermia: Hyperthermia (elevated body temperature). is not a typical finding associated with magnesium sulfate. Instead, magnesium sulfate can sometimes cause mild flushing, but it does not generally lead to an increase in body temperature.
Correct Answer is C
Explanation
A. "Clean the client's skin with soap and hot water" is incorrect. Soap and hot water can be harsh on the skin and can cause irritation, especially in clients who are at risk for skin breakdown. The nurse should use lukewarm water and a gentle cleanser to clean the skin.
B. "Limit the client's fluid intake" is incorrect. Limiting fluid intake is not a recommended approach for preventing skin breakdown. Proper hydration helps maintain skin elasticity and prevent dryness.
C. "Use a moisture barrier on the client's skin" is correct. A moisture barrier is crucial for protecting the skin from prolonged exposure to moisture from incontinence, which can lead to skin breakdown. The barrier helps prevent irritation and allows the skin to stay intact.
D. "Massage the area around the client's coccyx" is incorrect. Massaging over bony prominences, such as the coccyx, is not recommended, as it can damage tissue and increase the risk of pressure ulcers. The nurse should avoid massaging these areas.
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