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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Limiting fluid intake to 1 liter per day can lead to dehydration and other health complications. It is important for the client to maintain adequate hydration, especially postpartum. This option is incorrect and potentially harmful.
Choice B rationale:
Manual expression of milk can help relieve engorgement without stimulating further milk production. This method allows the client to express milk as needed. However, it can be done even before engorgment occurs
Choice C rationale:
Wearing a snug-fitting bra can provide support and comfort.
Choice D rationale:
Applying moist heat to the breasts can stimulate milk production and relieve engorgement. However, in this case, the client wants to suppress lactation. Therefore, this option is not appropriate and may have the opposite effect of increasing milk production.
Correct Answer is A
Explanation
a. Improves muscle strength.
Explanation:
Neostigmine is a medication used in the treatment of myasthenia gravis (MG). It belongs to a class of drugs called cholinesterase inhibitors. Neostigmine works by inhibiting the breakdown of acetylcholine, a neurotransmiter involved in muscle contraction. In MG, there is a decrease in the amount of acetylcholine available at the neuromuscular junction, leading to muscle weakness and fatigue.
By inhibiting the breakdown of acetylcholine, neostigmine helps to increase the concentration of acetylcholine at the neuromuscular junction. This, in turn, improves muscle strength and can alleviate the symptoms of weakness and fatigue associated with MG.
Option b, destroying the antibodies that cause MG, is not accurate. Myasthenia gravis is an autoimmune disorder characterized by the presence of antibodies that interfere with neuromuscular transmission.
Neostigmine does not directly target or eliminate these antibodies.
Option c, enhancing immune system function, is not accurate either. Neostigmine primarily acts on the neuromuscular junction to improve muscle strength and does not have a direct effect on immune system function.
Option d, preventing excessive coughing, is not the primary action of neostigmine. While increased muscle strength may indirectly improve respiratory function and reduce coughing in individuals with myasthenia gravis, it is not the primary indication or action of neostigmine.
Therefore, the most accurate information to include in teaching about neostigmine for a client with myasthenia gravis is that it improves muscle strength.
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