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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I should place a rolled blanket along each side of my baby's head in the car seat." - Incorrect. Placing rolled blankets on each side of the baby's head is not recommended as it can increase the risk of suffocation. Infants should be positioned in the car seat without any extra padding or blankets.
B. "I should place my baby's car seat rear-facing until 6 months of age." - Correct. Rear- facing car seats are recommended for infants until they reach at least 2 years of age or until they outgrow the weight and height limits specified by the car seat manufacturer. This position provides the best protection for the baby's head, neck, and spine in the event of a crash.
C. "I should put the car seat retainer clip at the level of my baby's belly button." - Incorrect. The retainer clip should be positioned at armpit level to secure the harness straps properly.
D. "I should position my baby's car seat at a 90-degree angle in the car." - Incorrect. Car seats should be installed at the appropriate recline angle according to the manufacturer's instructions, which may vary depending on the specific car seat model and the child's age and size.
Correct Answer is D
Explanation
A. Wearing an N95 respirator is not necessary when caring for a client with neutropenia due to HIV unless the client has respiratory symptoms or is undergoing procedures that generate aerosols.
B. Inserting an indwelling urinary catheter should be avoided unless necessary, as it can
introduce the risk of infection, which is particularly concerning in clients with neutropenia.
C. Monitoring vital signs every 8 hours may not provide sufficient frequency for detecting changes in a client with neutropenia who may be at risk for rapid deterioration.
D. Using a dedicated stethoscope helps prevent the spread of infection to other clients by avoiding cross-contamination, which is especially important when caring for a client with neutropenia who is at increased risk of infection.
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