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.

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Troponin is a protein released into the bloodstream when there is damage to the heart muscle (myocardium), such as during a heart attack. Elevated troponin levels indicate myocardial injury or damage, making this the correct choice for indicating myocardial damage.

B. Erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells settle in a tube of blood. It is a non-specific marker of inflammation and is not specific to myocardial damage.

C. Human B-type natriuretic peptide (BNP) is released by the heart in response to increased pressure and volume. Elevated levels are indicative of heart failure, not necessarily myocardial damage.

D. Activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot. It is used to monitor the effectiveness of anticoagulant therapy and is not specific to myocardial

damage.

A. Portable suction B. Cervical collar C. Hemodialyzer D. Pulse oximeter

Correct Answer is D

Explanation

A. Portable suction may be needed for some infants but is not specifically indicated for tetralogy of Fallot.

B. A cervical collar is used for neck support in patients with suspected cervical spine injuries and is not indicated for tetralogy of Fallot.

C. A hemodialyzer is used for renal replacement therapy and is not indicated for tetralogy of Fallot.

D. A pulse oximeter is essential for monitoring oxygen saturation levels in infants with tetralogy of Fallot, as they may experience cyanosis and hypoxemia. Monitoring oxygen saturation helps guide interventions and management.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage?

Correct Answer is A

Explanation

A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment?

Correct Answer is D

Explanation

A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following findings requires immediate intervention by the nurse?

A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first?

A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective?

A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following Instructions should the nurse include?

A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?