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 A
Explanation
A. "Verify the medication three times with the medication administration record.": This is the best practice for ensuring the correct medication is administered. The nurse should verify the medication when removing it from storage, before preparing the medication, and at the bedside before giving it to the patient to ensure the right drug, dose, patient, time, and route.
B. "Administer time-critical medication 60 min before or after the scheduled time.": Time-critical medications should be administered within a specified window of 30 minutes before or after the scheduled time, not 60 minutes. Administering medication too early or late could compromise its effectiveness.
C. "Identify the client by using one identifier before giving the medication.": The correct approach is to use two identifiers (e.g., name and date of birth) to verify the client's identity, not just one. This reduces the risk of medication errors.
D. "Document medication administration prior to administering medication.": Documentation should occur after medication administration, not before, to ensure accurate recordkeeping of the event.
Correct Answer is A
Explanation
A. Chicken sandwich is correct. In kosher dietary practices, poultry such as chicken is allowed, as long as it is prepared according to kosher guidelines. It is permissible for a client who follows kosher dietary practices to have a chicken sandwich, provided the bread and other ingredients are also kosher.
B. Cheeseburger is incorrect. Kosher dietary laws prohibit mixing meat and dairy. A cheeseburger would violate this rule because it contains both meat (beef) and dairy (cheese..
C. Shrimp and french fries is incorrect. Shellfish, including shrimp, is not allowed in a kosher diet. Kosher dietary practices prohibit eating shellfish and other non-kosher seafood.
D. Bacon and eggs is incorrect. Pork products, including bacon, are strictly forbidden in kosher dietary practices, so this would not be an appropriate choice for a client following kosher dietary laws.
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