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. Encouraging the client to write about her feelings in a journal each day.: While journaling can be therapeutic, it may not be the best immediate intervention. The client may first need support and validation of her feelings before engaging in such an activity.
B. Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds.: This is important for maintaining therapeutic communication, but it does not address the emotional distress the client is currently experiencing.
C. Identifying the client's perception of the changes in her physical appearance.: The client is likely struggling with body image changes following a bilateral mastectomy. The priority should be to assess the client’s emotional response to her altered appearance and to offer emotional support. This provides the foundation for helping the client process her feelings.
D. Providing the client with information on community resources that will strengthen her coping skills.: While community resources can be helpful later on, the immediate priority is understanding the client’s emotional response to her surgery. Once the nurse has established the client's emotional needs, then providing resources may be more appropriate.
Correct Answer is B
Explanation
A. "I can have a meal up to 2 hours before the procedure.": This is not correct. Clients are typically instructed to fast for at least 8 hours before an intravenous pyelogram to ensure clear imaging results and reduce the risk of complications from anesthesia or contrast media.
B. "I will feel a warming sensation after the injection of the dye contrast.": This is correct. It is common for clients to experience a warm sensation when the contrast dye is injected during the procedure.
C. "I do not need to sign a consent form before this procedure.": This is incorrect. A consent form is required before the procedure as it involves the use of contrast dye and potential risks, such as allergic reactions.
D. "I should limit my fluid intake for 2 days after the procedure.": This is not correct. After the procedure, clients are usually encouraged to drink plenty of fluids to help flush the contrast dye from the body and prevent potential kidney complications.
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