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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Expressing conflict over independence and control is incorrect. This behavior is more characteristic of adolescents, who struggle with autonomy as they develop their identity. Nine-year-old children are still largely influenced by parents and rules.

B. Demonstrating self-centered thinking is incorrect. Egocentric thinking is typical in preschool-aged children, while school-aged children develop the ability to see other perspectives and think more logically.

C. Displaying emotional detachment from parents is incorrect. While school-aged children begin to form peer relationships, they typically maintain strong emotional connections with their parents rather than detaching from them.

D. Grasping the concept of cause-and-effect is correct. At this stage, children develop logical thinking and an understanding of consequences, allowing them to recognize how actions lead to specific outcomes.

A. The client's potassium level is 2.7 mEq/L B. The client resumes menstruation. C. The client's pulse rate is 44/min. D. The client develops lanugo.

Correct Answer is B

Explanation

A. The client's potassium level is 2.7 mEq/L is incorrect. A potassium level of 2.7 mEq/L is low and indicates hypokalemia, which is a life-threatening condition that can occur in anorexia nervosa, particularly if the client is engaging in behaviors like purging. This level should be addressed immediately, not considered a positive outcome.

B. The client resumes menstruation is correct. The resumption of menstruation is a positive outcome of treatment for anorexia nervosa. It indicates that the client's nutritional status has improved and that the body is starting to regain normal function after addressing issues like malnutrition and hormonal imbalances.

C. The client's pulse rate is 44/min is incorrect. A pulse rate of 44/min is bradycardia, which is a common sign of anorexia nervosa due to malnutrition and the body's attempt to conserve energy. While it may improve with treatment, this finding would not be considered a positive outcome.

D. The client develops lanugo is incorrect. Lanugo (fine, soft hair) typically develops in severe anorexia nervosa due to malnutrition and is a sign of starvation. The appearance of lanugo is not a positive outcome but rather a compensatory mechanism to retain heat, indicating that the client is still in a malnourished state.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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