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 A
Explanation
A.
A. "Your PICC line will allow long-term access for antibiotic therapy." - PICC lines are often used for long-term administration of medications, including antibiotics, due to their durability and ease of use.
B. "You should use a 5-milliliter barrel syringe to flush your PICC line at home." - The size of the syringe used to flush a PICC line depends on the facility's protocol and the client's specific
needs. Specific instructions regarding syringe size should be provided by the healthcare provider or nurse.
C. "Your PICC line must be placed in your nondominant arm." - The choice of arm for PICC line placement depends on various factors, including vein integrity and the client's comfort. There is no strict requirement for the PICC line to be placed in the nondominant arm.
D. "You should immobilize the arm with the PICC line using a sling." - Immobilizing the arm with a sling is not typically necessary after PICC line placement. Clients are usually instructed to avoid excessive movement and to keep the arm clean and dry to prevent complications.
Correct Answer is D
Explanation
A. Allergies to eggs are not typically a contraindication for a thyroid scan.
B. Latex allergies are not typically a contraindication for a thyroid scan unless latex-containing materials are involved in the procedure, such as gloves or adhesive bandages.
C. Allergies to peanuts are not typically a contraindication for a thyroid scan.
D. Iodine is the main component of the radioactive tracer used in a thyroid scan. If the client has a known allergy to iodine, it would be unsafe for them to undergo the scan.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.