A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?
The gastric residual volume is 250 mL following 2 hr of infusion.
The client is lying in a supine position.
The infusion pump for administering continuous feeding is turned off.
The enteral feeding bag and tubing are not dated.
The Correct Answer is B
A. A gastric residual volume of 250 mL following 2 hours of infusion may indicate potential intolerance to the feeding, but it is not necessarily an immediate emergency unless it exceeds the facility’s threshold for residuals.
B. The client lying in a supine position poses a significant risk for aspiration, especially following a laryngectomy, where airway protection is compromised. Immediate intervention is necessary to reposition the client and reduce the risk of aspiration pneumonia.
C. While the infusion pump being off is concerning, it may not require immediate intervention as long as the nurse is aware and can address it promptly.
D. Not dating the enteral feeding bag and tubing is important for infection control; however, it does not require immediate intervention compared to the risk posed by a supine position.
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Related Questions
Correct Answer is C
Explanation
A. "Limit your meals to three times per day." - Incorrect. Following gastric bypass surgery,
clients are typically advised to eat small, frequent meals rather than limiting to three large meals per day.
B. "Consume at least 25 grams of fiber daily." - Incorrect. While fiber is important for gastrointestinal health, clients following gastric bypass surgery may need to avoid high-fiber foods initially and gradually reintroduce them based on individual tolerance.
C. "Start each meal with a protein source." - Correct. Protein is essential for wound healing and maintenance of muscle mass after gastric bypass surgery. Starting each meal with a protein source helps ensure an adequate intake.
D. "Check your blood glucose level before each meal." - This instruction is not directly related to dietary management following gastric bypass surgery. Blood glucose monitoring may be necessary for clients with diabetes, but it is not specific to post-gastric bypass dietary
instructions.
Correct Answer is D
Explanation
- Choice A: The recommended hepatitis vaccine series is not a series of four. The Advisory Committee on Immunization Practices (ACIP) recommends a three-dose series for hepatitis B vaccination.
- Choice B: Hepatitis B is not typically transmitted by contaminated food. It is primarily spread through direct contact with infectious blood, semen, or other body fluids.
- Choice C: While there is some evidence suggesting a link between chronic hepatitis C infection and an increased risk of renal cell carcinoma, the statement is not universally accepted as fact and more research is needed to establish a definitive connection.
- Choice D: Individuals with a history of hepatitis B or C are generally ineligible to donate blood due to the risk of transmission of these bloodborne viruses.
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