A nurse is assisting in the care of a client on the medical-surgical unit.
Which of the following client findings suggest that the nurse should hold the tube feeding and notify the provider? Select all that apply.
Laboratory electrolyte levels
Oxygen saturation
Abdominal findings
Blood glucose
Gastric residual
pH of gastric contents
Correct Answer : C,E,F
A. Laboratory electrolyte levels: The client’s potassium (3.7 mEq/L) and sodium (137 mEq/L) are within expected reference ranges. These values do not indicate electrolyte imbalance or metabolic instability that would require holding the feeding. Electrolyte disturbances can occur with enteral nutrition, but current results do not support discontinuation.
B. Oxygen saturation: An oxygen saturation of 96% on room air reflects adequate oxygenation and does not indicate aspiration or respiratory compromise. If aspiration from tube feeding had occurred, decreased oxygen saturation or respiratory distress might be present. Current findings do not justify holding the feeding based on oxygenation status.
C. Abdominal findings: A distended, firm, and tense abdomen suggests possible feeding intolerance, delayed gastric emptying, or bowel obstruction. These findings increase the risk for regurgitation and aspiration if feeding continues. Abdominal distention in the presence of enteral nutrition warrants holding the feeding and notifying the provider for further evaluation.
D. Blood glucose: A blood glucose of 152 mg/dL falls within the prescribed correction scale requiring 2 units of regular insulin. Mild hyperglycemia is common with enteral feedings and is addressed with sliding-scale insulin as ordered. This value alone does not require stopping the feeding.
E. Gastric residual: A gastric residual of 90 mL may indicate delayed gastric emptying, particularly when accompanied by abdominal distention. Elevated residual volumes increase the risk of aspiration if feeding continues. Clinical context, including abdominal findings, supports holding the feeding and notifying the provider.
F. pH of gastric contents: A pH of 6.4 is higher than expected for gastric contents, which are typically acidic (pH ≤5). An elevated pH raises concern for possible tube displacement into the respiratory tract or small intestine. This finding requires further verification of placement before continuing feedings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Hallucination: A hallucination is a sensory perception that occurs in the absence of an external stimulus. The client reports hearing special audible messages that no one else can hear, which indicates an auditory hallucination, a common symptom in schizophrenia.
A. Depersonalization: Depersonalization involves feelings of detachment from oneself, as if observing oneself from outside the body. The client’s statement does not reflect this experience.
C. Illusion: An illusion is a misinterpretation of an actual external stimulus (for example, mistaking a shadow for a person). In this case, there is no real external stimulus being misinterpreted.
D. Derealization: Derealization is a feeling that the external environment is unreal or distorted. The client’s experience of hearing voices does not indicate altered perception of the environment itself.
Correct Answer is D
Explanation
A. "Wash your newborn's head under a stream of running water.": Running water directly over a newborn’s head can increase the risk of aspiration or chilling. It is safer to use a damp washcloth to gently cleanse the scalp and hair, controlling the amount of water applied and maintaining the infant’s body temperature.
B. "Bathe your newborn within 30 minutes after a feeding.": Bathing immediately after feeding can increase the risk of spitting up or vomiting due to abdominal distension. It is recommended to wait at least 1 hour after feeding to allow digestion and reduce discomfort during the bath.
C. "Start the bath by washing the newborn's diaper area first.": The bath should always progress from the cleanest areas to the dirtiest areas to prevent the spread of bacteria from the genital region to more sensitive areas like the eyes and face.
D. "The bath water should be 100 to 103 degrees Fahrenheit.": Maintaining the bath water between 100 and 103 degrees is essential to prevent both hypothermia and thermal burns, as a newborn's skin is much thinner and more delicate than an adult's. This temperature range mimics the infant’s internal body temperature, providing a soothing environment.
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