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 B

Explanation

A. Incorrect. Withholding pain medications for 24 hr after the old patch is removed is a harmful action that could cause severe withdrawal symptoms and uncontrolled pain for the client. The nurse should respect the client's right to refuse treatment and explore the reasons for their decision.
B. Correct. Asking another nurse to witness the disposal of the new patch is a safe and legal action that follows the policies and procedures for handling controlled substances. The nurse should document the disposal of the new patch and report it to the appropriate authority.
C. Incorrect. Sealing the patches in a plastic bag and placing them in the client's trash basket is an unsafe and illegal action that could lead to diversion, misuse, or accidental exposure of fentanyl to others. The nurse should dispose of the patches in a secure and designated container that prevents access by unauthorized persons.
D. Incorrect. Sticking the two patches to each other and placing them in the sharps bin is an unsafe and improper action that could cause contamination, injury, or infection to others who handle or dispose of sharps waste. The nurse should dispose of the patches separately and carefully, avoiding contact with their adhesive surfaces.

A. Radial vein of the inner arm B. Great saphenous vein of the leg C. Dorsal plexus vein of the foot D. Basilic vein of the hand

Correct Answer is A

Explanation

- A. Radial vein of the inner arm. This is correct because this site is easily accessible, has good blood flow, and has less risk of complications such as infection, thrombosis, or infiltration.

- B. Great saphenous vein of the leg. This is incorrect because this site is not recommended for older adults due to poor circulation, increased risk of thrombophlebitis, and difficulty in monitoring.

- C. Dorsal plexus vein of the foot. This is incorrect because this site is prone to edema, infection, and injury, and can interfere with mobility and comfort.

- D. Basilic vein of the hand. This is incorrect because this site is more painful, has smaller veins, and can cause nerve damage or occlusion if not inserted carefully.

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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

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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?