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
The nurse should place the extremity in a dependent position before inserting an IV catheter.
This helps to dilate the veins and make them more visible and easier to access.
Choice A is wrong because the nurse should choose a site that is distal to the most proximal site on the extremity selected.
This helps to preserve more proximal sites for future use if needed.
Choice B is wrong because applying a cool compress before insertion of an IV catheter can cause vasoconstriction and make it more difficult to access the vein.
Instead, a warm compress can be applied to help dilate the veins.
Choice C is wrong because the tourniquet should be placed above, not below, the proposed insertion site to help dilate the vein and make it easier to access.
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.
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