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 B

Explanation

A) Hyperactive bowel sounds: Hypercalcemia typically leads to decreased gastrointestinal motility, not increased. Clients with elevated calcium levels may experience constipation, abdominal pain, or ileus due to the relaxing effect of calcium on smooth muscle. Therefore, hyperactive bowel sounds are not a common finding in hypercalcemia.

B) Increased blood clots: Hypercalcemia can promote a hypercoagulable state, increasing the risk of thromboembolic events. This occurs because high calcium levels can enhance platelet aggregation and increase the coagulability of blood. Therefore, a client with elevated serum calcium may have an increased risk of developing blood clots.

C) Hyperactive deep tendon reflexes: Hypercalcemia generally leads to reduced neuromuscular excitability, which may manifest as decreased or absent deep tendon reflexes, muscle weakness, and lethargy. Hyperactive reflexes are more commonly associated with hypocalcemia, which causes increased neuromuscular excitability.

D) Positive Chvostek’s sign: Chvostek's sign is a clinical indicator of hypocalcemia, not hypercalcemia. It involves twitching of the facial muscles in response to tapping the facial nerve and is due to increased neuromuscular excitability caused by low calcium levels. Hypercalcemia, conversely, does not typically present with a positive Chvostek’s sign.

A. Covering the client with a blanket B. Assessing the client's skin for a rash C. Notifying the provider D. Stopping the transfusion

Correct Answer is D

Explanation

A) Covering the client with a blanket:

Covering the client with a blanket may help manage chills, but it does not address the underlying cause of the symptoms. Stopping the transfusion takes precedence in ensuring patient safety.

B) Assessing the client's skin for a rash:

Assessing for a rash can help determine if an allergic reaction is occurring, but the priority is to stop the transfusion to prevent further complications and address the immediate risk.

C) Notifying the provider:

Notifying the provider is important for reporting and further management, but the immediate action should be stopping the transfusion to prevent potential adverse effects.

D) Stopping the transfusion:

Stopping the transfusion is the priority action as it addresses the immediate risk of a transfusion reaction, such as an allergic reaction or transfusion-related infection. This action helps prevent further complications and ensures the client's safety.

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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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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?