A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

Temperature 38.2° C (100.8° F)

Hematocrit 45%

Respiratory rate 12/min

Urine specific gravity 1.015

Answer and Explanation

The Correct Answer is A

A.   This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B.   Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues

or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C.   A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D.   Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.

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Correct Answer is A

Explanation

A. Administering tube feedings while the client is in a supine (flat on their back) position can increase the risk of aspiration. Ideally, clients should be positioned upright or at a 30-45 degree angle during and after tube feedings to reduce the risk of reflux and aspiration.
B. Flushing the NG tube with tap water after feeding is just a standard practice to prevent clogging and maintain tube patency.

C. Administering tube feedings by gravity using a syringe barrel is an appropriate method. This allows for controlled and slow administration of the feeding solution, minimizing the risk of overfeeding or complications.
D. Aspirating gastric residual before initiating tube feedings is a standard practice to assess the amount of residual contents in the stomach. However, the amount of residual aspirate that warrants intervention can vary based on institutional policies and the client's condition.

A. Place the client in a high Fowler's position. B. Ambulate the client twice daily. C. Mark abdominal girth once daily. D. Irrigate the nasogastric tube with tap water.

Correct Answer is C

Explanation

A. Place the client in a high Fowler's position:High Fowler’s would increase intra-abdominal pressure and strain sutures. For peritonitis recovery, semi-Fowler’s is preferred-promotes drainage of peritoneal fluid into the pelvis, preventing spread to diaphragm and lungs.

B. Ambulate the client twice daily:Too early after peritonitis lavage. Initially, the client is very weak, at risk for sepsis/shock. Early ambulation is not a priority here.

C. Mark abdominal girth once daily:Abdominal girth measurement is important to monitor for distention, fluid accumulation, or bleeding. Marking ensures accuracy in repeated measurements. This is a key intervention in monitoring postop peritonitis.

D. Irrigate the nasogastric tube with tap water:Never irrigate with tap water (risk of electrolyte imbalance, infection). Only sterile normal saline or as prescribed is used.

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A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed- suction drains in place. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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