A nurse is assessing a client who is receiving enteral feedings via ah NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?
Add water to the formula.
Reposition the NG tube.
Increase the rate of formula delivery.
Switch to a lactose-free formula.
The Correct Answer is A
A. Adding water to the formula will decrease its osmolarity, reducing the risk of hyperosmolar dehydration. This action helps to dilute the formula and make it more isotonic, which is better tolerated by the client's gastrointestinal tract.
B. Repositioning the NG tube may be necessary if there are issues with tube placement or if the tube has migrated. However, it is not directly related to addressing hyperosmolar dehydration.
C. Increasing the rate of formula delivery may exacerbate hyperosmolar dehydration by introducing more concentrated formula into the gastrointestinal tract, leading to further dehydration.
D. Switching to a lactose-free formula may be appropriate if the client has lactose intolerance, but it does not address the issue of hyperosmolar dehydration. Adding water to the formula is the more appropriate intervention in this scenario to decrease osmolarity and prevent dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "A health care surrogate must be a family member.": This statement is incorrect. A health care surrogate, also known as a health care proxy or agent, does not necessarily have to be a family member. It can be any individual chosen by the client to make health care decisions on their behalf if they become unable to do so.
B. "The client can resume control of health care after a temporary loss of competency.": This statement demonstrates an understanding of advance directives. Advance directives allow individuals to maintain control over their health care decisions by specifying their preferences for treatment or appointing a surrogate decision-maker. If a client experiences a temporary loss of competency, they can regain control of their health care decisions once competency is restored.
C. "The provider will choose a client's health care surrogate.": This statement is incorrect. It is the responsibility of the client to choose their health care surrogate. While healthcare providers may provide guidance and information about advance directives, they do not choose the surrogate for the client.
D. "The provider can go against the client's wishes regarding advance directives.": This statement is incorrect. Advance directives are legally binding documents that express a client's wishes regarding medical treatment. Healthcare providers are generally obligated to follow the directives outlined in these documents, and they cannot go against the client's wishes unless certain legal exceptions apply, such as emergency situations where immediate action is required to preserve life.
Correct Answer is C
Explanation
A. Initiate IV access on the palmar side of the client's wrist. - This option is not recommended because veins on the palmar side of the wrist are smaller and more prone to infiltration and nerve damage. The dorsal aspect of the hand or forearm is typically preferred for peripheral IV access due to larger veins and decreased risk of complications.
B. Choose the client's dominant arm for IV access whenever possible. - While it may be convenient to select the dominant arm for IV access, it is not always the best choice. Factors such as previous venipunctures, condition of veins, and patient comfort should be considered when selecting the site for IV insertion.
C. Select a site proximal to previous venipuncture sites. - This is the correct action. Choosing a site proximal (above) to previous venipuncture sites helps preserve veins and reduces the risk of venous sclerosis or phlebitis. It allows for better vein integrity and decreases the likelihood of complications associated with repeated punctures in the same area.
D. Insert a larger gauge IV catheter to prevent phlebitis. - Inserting a larger gauge IV catheter is not necessary to prevent phlebitis. In fact, using a larger gauge catheter may increase the risk of phlebitis and other complications. The appropriate gauge of the catheter depends on the client's condition, the type of fluids or medications to be administered, and the condition of the veins.
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