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?

Reposition the NG tube.

Increase the rate of formula delivery.

Add water to the formula.

Switch to a lactose-free formula.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Repositioning the NG tube is not the appropriate action for hyperosmolar dehydration. This condition occurs due to an excessive concentration of solutes in the body, leading to a decrease in intracellular water. Repositioning the tube would not address the hyperosmolarity issue.

Choice B rationale:

Increasing the rate of formula delivery may exacerbate the problem by introducing more concentrated formula into the client's system, worsening hyperosmolarity. This choice can lead to further dehydration and electrolyte imbalances.

Choice C rationale:

Adding water to the formula is the correct action in this scenario. Hyperosmolar dehydration requires dilution of the concentrated formula to reduce the osmolarity. By adding water to the formula, the nurse can decrease the concentration of solutes, helping to rehydrate the client effectively.

Choice D rationale:

Switching to a lactose-free formula is not the appropriate intervention for hyperosmolar dehydration. The issue lies in the concentration of the formula, not in its lactose content. Adding water is the more suitable and direct approach to address the problem.

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Correct Answer is C

Explanation

Choice A rationale:

Activating the fire alarm system is the second action the nurse should take after rescuing the individuals in the area.

Choice B rationale:

Obtaining and using a fire extinguisher should only be attempted by personnel trained to do so. Using a fire extinguisher incorrectly can escalate the fire or cause harm to individuals in the vicinity. The priority is to evacuate and let trained personnel handle the fire.

Choice C rationale:

Evacuating clients from the area is an essential and immediate step. Evacuation ensures the safety of everyone in the area, preventing potential harm due to smoke inhalation or fire spread.

Choice D rationale:

Closing the doors and windows on the unit can help contain the fire and prevent its spread. However, this action should be taken after activating the fire alarm system and initiating the evacuation process. Closing doors and windows can buy some time and limit the fire's oxygen supply, but it should not delay the evacuation procedure.

A. Hemoglobin 14.9 g/dL B. WBC count 12.000/mm C. Potassium 48 mEq D. BUN 18 mg/dL

Correct Answer is A

Explanation

A. Correct. A hemoglobin level of 14.9 g/dL indicates that the client has an adequate amount of oxygen-carrying capacity in the blood, which is the goal of blood transfusion therapy.
B. Incorrect. A WBC count of 12,000/mm3 is slightly elevated and may indicate an infection or inflammation, which are not related to blood transfusion therapy.
C. Incorrect. A potassium level of 48 mEq/L is dangerously high and may cause cardiac arrhythmias, muscle weakness, or paralysis. This is not an expected outcome of blood transfusion therapy and may indicate hemolysis or renal impairment.
D. Incorrect. A BUN level of 18 mg/dL is within the normal range and does not reflect the effectiveness of blood transfusion therapy.

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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?

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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?