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. Obtain urinary samples by disconnecting the tubing connections:
This action increases the risk of contamination and introduces bacteria into the urinary system, potentially leading to UTIs. Urine samples should be obtained using a sterile technique to minimize the risk of infection.
B. Secure the catheter to the client's thigh:
Securing the catheter to the client's thigh can cause tension and traction on the catheter, increasing the risk of urethral trauma and introducing bacteria into the urinary tract. Catheters should be secured without tension to prevent damage to the urethra and reduce the risk of UTIs.
C. Keep the urinary bag at bladder level when ambulating:
Keeping the urinary bag at bladder level when ambulating prevents urine from flowing back into the bladder, reducing the risk of UTIs. Gravity drainage helps maintain the flow of urine and prevents stasis, which can contribute to bacterial growth and UTIs.
D. Loop the tubing so that it is lower than the collection bag:
Looping the tubing so that it is lower than the collection bag creates a dependent loop where urine can accumulate, increasing the risk of bacterial colonization and UTIs. The tubing should be kept straight and free of kinks to ensure continuous drainage and prevent urine from pooling in the tubing.
Correct Answer is C
Explanation
A. Provide the client with a low-protein diet: Clients with severe preeclampsia may require dietary modifications, but a low-protein diet is not typically indicated. Instead, they may need a balanced diet with adequate protein intake to support maternal and fetal health.
B. Ambulate the client every 4 hr: Ambulation may not be suitable for a client with severe preeclampsia due to the risk of seizures and other complications associated with the condition. Bed rest or limited activity is often recommended to reduce the risk of adverse outcomes.
C. Ensure that the side rails are up on the client's bed: This action is crucial for the safety of the client with severe preeclampsia, as they are at risk of seizures, which can lead to injury from falls. Keeping the side rails up helps prevent falls and ensures the client's safety during periods of altered consciousness.
D. Check the fetal heart rate twice daily: Monitoring the fetal heart rate is essential in managing severe preeclampsia to assess fetal well-being and detect signs of fetal distress. However, the frequency of monitoring may vary depending on the severity of the condition and the healthcare provider's orders. More frequent monitoring may be necessary in some cases.
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