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 D
Explanation
According to the Centers for Disease Control and Prevention (CDC), tuberculosis (TB) infection control plan is part of a general infection control program designed to ensure prompt detection of infectious TB patients, airborne precautions, and treatment of people who have suspected or confirmed TB disease.
Choice A, Contact precautions, are not necessary for TB patients as TB is not spread through contact.
Choice B, Protective precautions, are used to protect immunocompromised patients from infections and are not necessary for TB patients.
Choice C, Droplet precautions, are used for diseases that are spread through large respiratory droplets and are not necessary for TB patients as TB is spread through airborne droplet nuclei.
Correct Answer is D
Explanation
During the contemplation stage of health behavior change, the client is thinking about change and becoming motivated to get started.
The nurse should present information about the benefits of quitting smoking to help the client assess the benefits of change.
Choice A is not correct because developing a plan for the client to integrate the change into her lifestyle is more appropriate for the preparation stage.
Choice B is not correct because recommending small changes for the client to make to change her behavior over time is more appropriate for the action stage.
Choice C is not correct because assisting the client in setting goals to make the change is more appropriate for the preparation stage.
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