A nurse is assessing a client who is receiving enteral feedings via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?
Switch to a lactose-free formula.
Reposition the NG tube.
Increase the rate of formula delivery.
Add water to the formula.
The Correct Answer is D
A. Switch to a lactose-free formula – A lactose-free formula is necessary for clients with lactose intolerance but does not address the issue of hyperosmolar dehydration, which results from insufficient free water intake rather than intolerance to lactose.
B. Reposition the NG tube – Repositioning the tube is necessary if there is displacement, but it does not treat dehydration caused by hyperosmolar feedings.
C. Increase the rate of formula delivery – Increasing the rate can worsen dehydration by further increasing the solute load, leading to a greater fluid shift from intracellular to extracellular spaces.
D. Add water to the formula – This is the correct answer because hyperosmolar dehydration occurs when high-solute enteral formulas pull water into the intestines, leading to excessive fluid loss. To prevent this, the nurse should ensure the client receives adequate free water flushes alongside tube feedings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Crispy foods like rice bars can be difficult to swallow and increase the risk of aspiration.
B. Dry foods such as soda crackers require excessive chewing and can be a choking hazard.
C. This is the correct answer. Scrambled eggs have a soft, moist texture that is easy to chew and swallow, making them a good option for clients with dysphagia.
D. Peanut butter is thick and sticky, making it difficult to swallow and increasing aspiration risk.
Correct Answer is A
Explanation
A. Suction the client's airway – This is the correct answer. A high-pressure alarm on a ventilator usually indicates an obstruction, such as mucus plugging or secretions in the airway. Suctioning helps clear the obstruction.
B. Look for a leak in the tube's cuff – A leak would trigger a low-pressure alarm, not a high-pressure alarm.
C. Tighten the tubing connections – Loose connections generally cause low-pressure alarms rather than high-pressure alarms.
D. Request insertion of a tracheostomy tube – This may be necessary for long-term ventilation, but it is not the immediate intervention for a high-pressure alarm.
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