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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Insomnia is not a typical adverse effect of disulfiram-alcohol interaction.

B. Tinnitus is not commonly associated with disulfiram reactions.

C. This is the correct answer. Disulfiram causes an acetaldehyde accumulation reaction when alcohol is consumed, leading to symptoms such as headache, nausea, vomiting, and flushing.

D. Hypotension, not hypertension, is a more common response due to vasodilation from the reaction.

A. "I will be sure that all of my bottles contain BPA." B. "I can keep a can of concentrated formula in the refrigerator for 3 days after I open it." C. "I should boil tap water for 2 minutes and cool it before I mix it with the powdered formula." D. "I can dilute the ready-to-feed formula with water when my baby wants more than 4 ounces at a feeding."

Correct Answer is C

Explanation

A. BPA (bisphenol A) is harmful, and bottles should be BPA-free.

B. Concentrated formula should be used within 24–48 hours after opening if refrigerated, not 3 days.

C. This is the correct answer. Boiling tap water for 1–2 minutes and cooling it before mixing with powdered formula helps eliminate bacteria, ensuring safe consumption for newborns.

D. Diluting ready-to-feed formula is unsafe and can lead to inadequate nutrition for the baby.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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