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 B
Explanation
A. Family history of cardiovascular disease: This is a non-modifiable risk factor. Family history can increase the likelihood of cardiovascular disease, but it cannot be changed.
B. Cholesterol 240 mg/dL: This is a modifiable risk factor. High cholesterol levels, particularly above 200 mg/dL, increase the risk of cardiovascular disease, and they can be managed through lifestyle changes, diet, and medication.
C. Sex: This is a non-modifiable risk factor. Men are generally at higher risk for cardiovascular disease at a younger age, while the risk increases for women after menopause.
D. Age 65: This is a non-modifiable risk factor. As people age, their risk for cardiovascular disease increases.
Correct Answer is D
Explanation
A. "I will make sure that electrical wires are run under carpeting.": This is not a safe practice. Running electrical wires under carpeting can lead to the wires overheating or becoming damaged, which is a fire hazard.
B. "I will have the heating system inspected once every 3 years.": The heating system should be inspected more frequently than every three years, ideally annually, to ensure safety and proper functioning.
C. "I will have my hearing tested every 2 years.": While hearing should be monitored regularly, this is not a specific home safety measure. A hearing impairment can increase the risk of falls or accidents.
D. "I will make sure that my hot water faucets are color-coded.": This is an important safety measure, particularly for older adults, as it helps prevent burns. Color-coded faucets can help prevent the risk of hot water burns by easily identifying hot and cold water.
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