A nurse is assessing a client who is receiving an intermittent enteral feed through a nasogastric tube. Which finding is the nurse's PRIORITY to address?

The client is reporting constipation.

The client reports being thirsty

The client is vomiting the enteral formula.

The client is experiencing abdominal cramping.

Answer and Explanation

The Correct Answer is C

A) The client is reporting constipation:

Constipation is a common issue with enteral feeding, often due to decreased fluid intake or lack of fiber. While it is important to manage constipation to improve comfort and bowel function, it is not as urgent as dealing with vomiting.

B) The client reports being thirsty:

Thirst can be a sign of dehydration or inadequate fluid intake. Although it should be addressed to ensure proper hydration, it is less critical compared to vomiting, which poses immediate risks.

C) The client is vomiting the enteral formula:

Vomiting is a priority concern because it can lead to aspiration, dehydration, electrolyte imbalances, and further complications. Addressing the cause of vomiting and managing it promptly is crucial for the client’s safety.

D) The client is experiencing abdominal cramping:

Abdominal cramping can be related to the feeding rate, type of formula, or intolerance. While it requires attention, it is less urgent than addressing vomiting, which could have more immediate and serious consequences.

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Correct Answer is D

Explanation

A) Isotonic solution: Isotonic solutions, such as 0.9% sodium chloride, are used to maintain fluid balance and are not ideal for treating hypernatremia. They do not correct the elevated sodium levels and might even contribute to fluid overload.

B) Total Parenteral Nutrition (TPN): TPN is a form of nutrition provided intravenously and is not specifically used to manage electrolyte imbalances like hypernatremia. It is used for clients who cannot eat or absorb nutrients through the gastrointestinal tract.

C) Hypertonic solution: Hypertonic solutions, such as 3% sodium chloride, are used to treat hyponatremia or other conditions requiring increased sodium concentration. They would exacerbate hypernatremia rather than treat it.

D) Hypotonic solution: Hypotonic solutions, such as 0.45% sodium chloride (half-normal saline) or dextrose 5% in water (D5W), are appropriate for treating hypernatremia. These solutions help dilute the excess sodium in the blood, reduce serum sodium levels, and facilitate a gradual correction of the imbalance.

A. Mashed potatoes B. High-fiber cereals C. Fruit with the skin D. Raw vegetables

Correct Answer is A

Explanation

A) Mashed potatoes:

Mashed potatoes are an appropriate choice for a soft diet as they are easy to chew and swallow. A soft diet typically includes foods that are tender, moist, and easy to digest, which helps in minimizing difficulty while eating.

B) High-fiber cereals:

High-fiber cereals are not suitable for a soft diet. They can be hard and difficult to chew, and the high fiber content might irritate the digestive tract, making them less ideal for individuals on a soft diet.

C) Fruit with the skin:

Fruits with the skin can be difficult to chew and digest, especially for those on a soft diet. The skin of fruits can be tough and may not be appropriate for someone needing a diet with soft, easily manageable foods.

D) Raw vegetables:

Raw vegetables are typically hard and require thorough chewing, which makes them unsuitable for a soft diet. Soft diets require foods that are tender and easy to chew, so raw vegetables do not meet these criteria.

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﻿A nurse is assessing a client who is receiving an intermittent enteral feed through a nasogastric tube. Which finding is the nurse's PRIORITY to address?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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A nurse is assessing a client who is receiving an intermittent enteral feed through a nasogastric tube. Which finding is the nurse's PRIORITY to address?