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 A

Explanation

A) Speech Therapist: A speech therapist is the appropriate professional for assessing and managing dysphagia, especially in clients who have experienced a stroke. They specialize in evaluating swallowing function, determining the safest consistencies of food and liquids, and providing strategies or exercises to improve swallowing ability. They play a critical role in deciding the safest method of feeding, whether it involves modified diets or alternative feeding methods.

B) Respiratory Therapist: Respiratory therapists focus on assessing and managing respiratory conditions. While they may become involved if there are concerns about aspiration leading to respiratory complications, they do not directly manage dysphagia or feeding issues.

C) Physical Therapist: Physical therapists work primarily on improving gross motor skills, mobility, and physical function. They do not specialize in swallowing disorders or feeding methods, so they are not the primary professionals to consult for issues related to dysphagia.

D) Occupational Therapist: Occupational therapists can assist clients with fine motor skills and daily living activities, which may include feeding. However, they do not specialize in assessing or treating swallowing disorders. Their role would be more focused on helping clients with the practical aspects of self-feeding once safe swallowing methods are established by a speech therapist.

A. 8 hr B. 4 hr C. 6 hr D. 2 hr

Correct Answer is D

Explanation

A. 8 hr - Infusing one unit of packed red blood cells (PRBCs) over 8 hours is too long. Typically, PRBCs are infused over a shorter period to avoid complications.

B. 4 hr - Infusing PRBCs over 4 hours is still within acceptable limits, but the standard time for PRBC transfusion is usually shorter.

C. 6 hr - Infusing PRBCs over 6 hours is longer than usual. The recommended duration for infusing one unit of PRBCs is generally shorter.

D. 2 hr - The standard time to infuse one unit of PRBCs is typically between 1.5 to 2 hours. This duration helps ensure the effective delivery of red blood cells while minimizing the risk of transfusion reactions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is suffering from dysphagia after a stroke and is currently NPO. Which member of the inter-professional team would the nurse anticipate will be consulted to determine how this client will be safely fed?

Correct Answer is A

Explanation

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Correct Answer is D

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?