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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Decreased impulsiveness: Methylphenidate is a central nervous system stimulant commonly used to treat attention deficit hyperactivity disorder (ADHD) in children. One of the therapeutic effects of methylphenidate is the reduction of impulsiveness, hyperactivity, and inattention, which are hallmark symptoms of ADHD. Therefore, a decrease in impulsiveness would indicate that the medication is effective.
B. Increased urine output: Methylphenidate is not expected to affect urine output. Increased urine output is not a typical finding indicating the effectiveness of methylphenidate.
C. Increased appetite: Methylphenidate commonly causes appetite suppression as a side effect. Therefore, an increase in appetite would not be indicative of the medication's effectiveness. In fact, a decrease in appetite is a common adverse effect of methylphenidate.
D. Decreased abdominal pain: Methylphenidate is not typically used to treat abdominal pain, and its effectiveness is not evaluated based on the relief of abdominal pain. The primary therapeutic effect of methylphenidate in ADHD is the improvement of attention, focus, and impulse control. Therefore, decreased abdominal pain would not be a reliable indicator of the medication's effectiveness.
Correct Answer is B
Explanation
A. "I will position the shoulder harness straps 3 inches above my baby's shoulders.": The shoulder harness straps should be positioned at or below the baby's shoulders, not above them, to ensure proper restraint in the event of a crash. Placing the straps too high can increase the risk of injury to the baby.
B. "I will position my baby at a 45-degree angle in the car seat.": This statement indicates an understanding of proper car seat positioning for a newborn. Newborns should be positioned at a 45-degree angle in a rear-facing car seat to keep the airway open and prevent head flopping, which can restrict breathing. This angle helps to keep the baby's head from falling forward and blocking the airway.
C. "I will turn the car seat forward-facing when my baby is 1 year old.": It is recommended to keep infants in a rear-facing car seat until they reach the maximum weight or height limit specified by the car seat manufacturer, typically around 2 years of age. Turning the car seat forward-facing prematurely increases the risk of injury to the baby's head, neck, and spine in the event of a crash.
D. "I will place the retainer clip on my baby's upper abdomen.": The retainer clip, also known as the chest clip, should be positioned at armpit level to properly secure the harness straps over the baby's shoulders. Placing the clip on the baby's upper abdomen can result in improper restraint and increase the risk of injury in a crash.
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