A nurse is caring for a client who is receiving continuous enteral tube feeding and reports cramping and abdominal distention. Which of the following actions should the nurse take?

Choice A rationale:
A temperature of 37.2°C (99°F) is within the normal range (approximately 36.5°C to 37.5°C or 97.7°F to 99.5°F) and does not specifically indicate fluid volume deficit. It's important to consider this value along with other findings.
Choice B rationale:
(Correct Choice) A pulse rate of 118/min is indicative of tachycardia, which can be a sign of fluid volume deficit. When the body is experiencing a decrease in fluid volume, the heart rate often increases as a compensatory mechanism to maintain adequate circulation. Tachycardia helps to pump a reduced blood volume more rapidly to vital organs.
Choice C rationale:
A blood pressure of 152/90 mm Hg is elevated but does not solely indicate a fluid volume deficit. While low blood pressure can be a sign of dehydration, high blood pressure does not necessarily correlate directly with fluid volume status.
Choice D rationale:
Central venous pressure (CVP) of 25 mm Hg is elevated. CVP reflects the pressure in the vena cava and right atrium, indicating the amount of blood returning to the heart. An elevated CVP might be seen in fluid volume excess or right-sided heart failure, not fluid volume deficit.

Choice Arationale:
Rye toast with herbal tea is also not appropriate for someone with celiac disease. Rye bread contains gluten, and even though herbal tea is gluten-free, the combination with rye toast would still be harmful to the client.

Choice Brationale:
Graham crackers with peanut butter are not suitable for a client with celiac disease. Graham crackers are typically made from wheat flour, which contains gluten, a protein that individuals with celiac disease must avoid to prevent intestinal damage.

Choice C rationale:
The correct choice is rice cereal with sliced bananas. Rice cereal is naturally gluten-free and therefore safe for individuals with celiac disease. Sliced bananas can add flavor and nutrients to the meal without causing any harm to the client's condition.
Choice D rationale:
Poached eggs with wheat bagel is an unsuitable option. Wheat bagels contain gluten, which is harmful to individuals with celiac disease. Even though poached eggs are gluten-free, the risk of cross-contamination from the wheat bagel would be too high for this client.