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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Chadwick's sign: Chadwick's sign is related to pregnancy and refers to the bluish discoloration of the cervix and vaginal walls due to increased blood flow. It is not associated with calcium levels or postoperative thyroidectomy.
B) Murphy's sign: Murphy's sign is used to diagnose gallbladder inflammation or cholecystitis. It involves palpation of the right upper quadrant of the abdomen and is not related to calcium levels or thyroid surgery.
C) Babinski's sign: Babinski's sign is a neurological reflex test used to assess the presence of upper motor neuron lesions. It is not associated with calcium levels or postoperative thyroidectomy.
D) Chvostek's sign: Chvostek's sign is a clinical indicator of hypocalcemia, where tapping on the facial nerve causes twitching of the facial muscles. With the client's calcium level of 3 mg/dL, which is significantly low, Chvostek's sign would likely be positive, indicating hypocalcemia.
Correct Answer is C
Explanation
A) The client's daily calorie intake: While daily calorie intake is important for understanding a client's nutritional needs and managing their diet, it is not required for calculating BMI. BMI calculation focuses on weight and height rather than caloric intake.
B) The client's waist circumference: Waist circumference is useful for assessing abdominal fat distribution and risk of obesity-related conditions, but it is not needed for calculating BMI. BMI calculation requires height and weight, not waist measurements.
C) The client's height: To calculate BMI, the client's height is essential. BMI is determined by dividing weight in kilograms by the square of height in meters (kg/m²). Accurate height measurement is crucial for this calculation.
D) The client's skinfold thickness: Skinfold thickness measurements are used to estimate body fat percentage but are not required for calculating BMI. BMI relies solely on weight and height, not body fat estimates.
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