A nurse is caring for 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?
Gastric content pH
Abdominal findings
Oxygen saturation
Gastric residual
Blood glucose
Laboratory electrolyte levels
Correct Answer : B,D
A. Gastric content pH: The pH of the gastric aspirate increased from 4.8 to 6.4, which may indicate a change in gastric emptying or possible contamination with intestinal contents. However, a pH of 6.4 alone is not an immediate reason to hold enteral feeding unless accompanied by other concerning signs.
B. Abdominal findings: The client has a distended, firm, and tense abdomen, which may indicate intolerance to the tube feeding, delayed gastric emptying, or possible bowel obstruction. These physical findings require immediate attention because continuing enteral feeding could worsen complications such as vomiting, aspiration, or bowel perforation.
C. Oxygen saturation: The client’s oxygen saturation is 96% on room air, which is within normal limits. While hypoxia can be a sign of aspiration or respiratory compromise, the current oxygenation does not indicate an immediate need to hold feeding or notify the provider.
D. Gastric residual: A residual volume of 90 mL with a pH of 6.4 suggests delayed gastric emptying or intolerance of the feeding. High residuals increase the risk of aspiration and indicate that the client may not tolerate additional enteral nutrition. Holding the feeding and notifying the provider is warranted to prevent complications.
E. Blood glucose: The client’s blood glucose is slightly elevated at 152 mg/dL, which falls within the range for administering correctional insulin per provider orders. Although ongoing monitoring is important, this glucose level does not require holding the feeding.
F. Laboratory electrolyte levels: The client’s potassium (3.7 mEq/L) and sodium (137 mEq/L) are within normal limits. There are no electrolyte abnormalities that would necessitate holding the tube feeding at this time, though continued monitoring is important for ongoing nutritional support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply oxygen at 3 L/min per nasal cannula: Oxygen administration is not a routine requirement after CVC insertion unless the client is experiencing respiratory distress or hypoxia. It is not necessary prior to starting an IV infusion.
B. Review the chest x-ray report: After insertion of a subclavian CVC, a chest x-ray is required to confirm correct catheter placement and to rule out complications such as pneumothorax. Reviewing the report ensures it is safe to initiate IV fluids through the catheter.
C. Flush the catheter with sterile water: Central lines should be flushed with saline, not sterile water, to maintain patency. Flushing with water can cause hemolysis and is unsafe.
D. Obtain a peripheral blood glucose level: Blood glucose monitoring is not directly related to CVC insertion or initiation of IV fluids unless specifically indicated by the client’s medical condition. It is not a standard preparatory action for starting an infusion.
Correct Answer is D
Explanation
A. Treat mild to moderate depression: Chondroitin and glucosamine do not have antidepressant properties and are not indicated for the treatment of mood disorders. Their mechanism of action is focused on cartilage support, not neurotransmitter modulation or mood regulation.
B. Enhance the immune system: While some supplements may influence immune function, chondroitin and glucosamine are not used for immunomodulation. Their primary role is in musculoskeletal health rather than preventing infections or altering immune responses.
C. Prevent and treat prostate enlargement: These supplements have no effect on prostate tissue or hormonal pathways related to benign prostatic hyperplasia. They are not indicated for urinary or prostate health and do not prevent prostate enlargement.
D. Improve joint functioning: Chondroitin and glucosamine are commonly used to support cartilage structure, reduce joint pain, and improve mobility in conditions such as osteoarthritis. They help maintain joint integrity and may decrease symptoms associated with cartilage degeneration, promoting better overall joint function.
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