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. Weight gain is a sign of hypothyroidism, not thyrotoxicosis.

B. Bradycardia is associated with hypothyroidism, whereas thyrotoxicosis causes tachycardia.

C. This is the correct answer. Fever is a symptom of thyrotoxicosis, which results from excessive thyroid hormone levels, leading to hypermetabolism. Other signs include tachycardia, anxiety, heat intolerance, and weight loss.

D. Drowsiness is more commonly associated with hypothyroidism.

A. Temperature B. Respiratory rate C. SpO2 D. pH

Correct Answer is C

Explanation

A. Temperature: 37.2°C (99.0°F) is within the normal range.

B. Respiratory rate: 28/min is elevated but expected in COPD.

C. An SpO₂ of 88% indicates significant hypoxemia in a client with COPD, which requires immediate intervention. Oxygen therapy may be needed to maintain a target saturation of 88–92%.

D. pH: 7.22 indicates respiratory acidosis but is consistent with COPD and requires monitoring rather than immediate notification.

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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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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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