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 D
Explanation
A. Wear a bra with wire support: This is not recommended immediately after a modified radical mastectomy, as it can put pressure on the surgical site and cause discomfort or interfere with healing. Instead, the client should wear a soft, supportive bra without underwire to provide comfort and support.
B. Use deodorant under the affected arm: Applying deodorant under the affected arm is generally not recommended immediately after surgery, as the area may be sensitive and the skin may be healing. The client should avoid applying deodorant until the surgical site has healed and they have consulted with their healthcare provider.
C. Begin ball squeezing exercises: While exercises to improve range of motion and strength in the affected arm are important after a mastectomy, initiating them on the first day postoperative may be too early. The client should follow the specific instructions provided by their healthcare provider regarding when to begin exercises and which exercises are appropriate.
D. Avoid using the affected arm for eating: This is the most appropriate instruction for the client. After a modified radical mastectomy, the affected arm may be temporarily restricted in movement or may be sensitive. To avoid strain or discomfort, the client should avoid using the affected arm for activities such as eating until they receive further guidance from their healthcare provider.
Correct Answer is D
Explanation
A. Attach a dosimeter to the client's gown: A dosimeter measures the radiation dose received by the wearer over a period of time. While healthcare providers and personnel working closely with the client during brachytherapy may wear dosimeters, attaching one to the client's gown is not a standard practice.
B. Strain the client's urine: Straining the client's urine is not directly related to the care required for a client undergoing brachytherapy. The primary focus of care during brachytherapy is to minimize radiation exposure to others and promote the client's comfort and safety.
C. Limit each of the client's visitors to 2 hr per day: While it may be appropriate to limit the duration of visits to reduce the potential radiation exposure of visitors, the specific time limit of 2 hours per day is not standard and should be determined based on individual circumstances and institutional policies.
D. Instruct visitors to stay 1 m (3.3 feet) away from the client: This intervention is appropriate because it helps minimize radiation exposure to visitors. Maintaining distance from the client reduces the risk of radiation exposure to others while still allowing for social interaction and support during the client's treatment.
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