A nurse is caring for a client who is receiving continuous enteral feeding via NG tube.
Which of the following is an unexpected finding?
Gastric residual of 300 mL at the end of the shift.
Weight gain of 0.91 kg (2 Ib) in 2 days.
Blood glucose level of 110 mg/dL.
Diarrhea one time in a 24-hr period.
The Correct Answer is A
Gastric residual of 300 mL at the end of the shift is an unexpected finding.
Gastric residual volume refers to the volume of fluid remaining in the stomach during enteral feeding.
A gastric residual volume of less than or equal to 500 mL every 6 hours is considered safe and indicates that the gastrointestinal tract is functioning.
Choice B is wrong because weight gain is expected during enteral feeding.
Choice C is wrong because a blood glucose level of 110 mg/dL is within the normal range.
Choice D is wrong because diarrhea can be a common side effect of enteral feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choicec. “You will need to wear a mask when outside of your room.”
Choice A rationale:
Visitors wearing protective gowns is important to prevent infection, but it is not the primary teaching point for the patient themselves.
Choice B rationale:
Patients undergoing allogeneic stem cell transplants are typically placed in private rooms to minimize the risk of infection, not semi-private rooms.
Choice C rationale:
Wearing a mask when outside the room is crucial for the patient to protect themselves from infections due to their compromised immune system during the transplant process.
Choice D rationale:
Negative-airflow rooms are used to prevent the spread of airborne infections from the patient to others, not necessarily to keep the air cleaner for the patient.
Correct Answer is B
Explanation
Prepare the client for a central venous line.
Parenteral nutrition (PN) with 20% dextrose and fat emulsions is a hypertonic solution that requires infusion through a central venous line to prevent damage to peripheral veins.
Choice A is wrong because the PN infusion bag should be changed every 24 hours, not every 48 hours.
Choice Cis wrong because blood glucose should be monitored more frequently than once daily when initiating PN therapy.
Choice Dis wrong because PN and fat emulsions can be administered together in a total nutrient admixture (TNA)1.
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