A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To confirm the placement of the NG tube

To determine the client's electrolyte balance

To remove gastric acid that might cause dyspepsia

To identify delayed gastric emptying

Answer and Explanation

The Correct Answer is D

The nurse should measure the gastric residual before administering a feeding to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. Measuring gastric residual helps assess how well the client's stomach is emptying and can indicate if there is delayed gastric emptying.

By measuring gastric residual, the nurse can:

● Determine if the stomach has adequately emptied from the previous feeding. ● Assess the client's tolerance to enteral feedings.

● Detect signs of delayed gastric emptying, which can be indicative of gastrointestinal motility issues or other complications.

● Adjust the feeding rate or make other modifications to the enteral feeding plan based on the amount of residual volume.

Confirming the placement of the NG tube is typically done using other methods, such as an X-ray, pH testing, or auscultation of air insufflation. Gastric residual measurement primarily serves the purpose of assessing gastric emptying, rather than confirming tube placement.

While electrolyte imbalances can be monitored in the overall care of a client receiving enteral feedings, measuring gastric residual specifically focuses on assessing gastric emptying and feeding tolerance, rather than determining the client's electrolyte balance.

Removing gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. Gastric residual measurement aims to evaluate the volume of the previous feeding and assess gastric emptying, rather than focusing on dyspepsia specifically.

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Free Nursing Study Resources

Correct Answer is ["B","D"]

Explanation

When reinforcing teaching with a client who has a duodenal ulcer and a new prescription for cimetidine, the nurse should include the following instructions:

"Avoid taking the medication at bedtime.": Cimetidine is most effective when taken during waking hours to help control gastric acid secretion. Taking it at bedtime may not provide optimal therapeutic benefits.

"You will need to continue taking this medication for up to 6 weeks.": Cimetidine is often prescribed for the treatment of duodenal ulcers and may require several weeks of continuous use to promote healing. It is important for the client to understand the duration of treatment and the need for adherence to the prescribed regimen.

The following statements are incorrect or not applicable:

"Drinking grapefruit juice while taking cimetidine can lead to toxicity.": Cimetidine does not have a known interaction with grapefruit juice. However, it is always important to consult the healthcare provider or pharmacist about potential drug interactions, including those related to specific foods or beverages.

"Take an antacid 30 minutes prior to taking cimetidine to minimize stomach upset.": Cimetidine is an H2 receptor antagonist that works by reducing stomach acid production. It is not necessary to take an antacid prior to taking cimetidine to minimize stomach upset. However, if the client experiences stomach upset or discomfort, they should consult their healthcare provider for further guidance on managing these symptoms.

A. Administer an enteral feeding to a client who has a new gastrostomy tube. B. Measure the output from a client's indwelling urinary catheter. C. Evaluate a client's pain level 30 min after receiving an oral analgesic. D. Reinforce foot care to a client who has a new diagnosis of diabetes mellitus.

Correct Answer is B

Explanation

Measuring the output from an indwelling urinary catheter is within the scope of practice for an assistive personnel (AP). It involves a straightforward task that does not require specialized nursing knowledge or judgment.

The other tasks mentioned should not be delegated to an AP:

Administer an enteral feeding to a client who has a new gastrostomy tube: Administering enteral feedings requires specialized knowledge and training to ensure proper placement and administration. This task should be performed by a licensed nurse.

Evaluate a client's pain level 30 min after receiving an oral analgesic: Evaluating pain level and the effectiveness of pain management requires nursing assessment and judgment. This task should be performed by a licensed nurse.

Reinforce foot care to a client who has a new diagnosis of diabetes mellitus: Providing education and reinforcing foot care to a client with a new diagnosis of diabetes requires

specialized knowledge about the disease and its management. This task should be performed by a licensed nurse.

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A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a duodenal ulcer and a new prescription for cimetidine. Which of the following instructions should the nurse include?

Correct Answer is ["B","D"]

Explanation

A charge nurse planning care for a group of clients is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Correct Answer is B

Explanation

A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?

A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?

A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

A nurse is collecting data from a client who has been taking omeprazole for the past 4 weeks. The nurse determines that the medication is effective when the client reports relief from which of the following symptoms?

A nurse assisting a provider with a sterile procedure prepares to pour a sterile solution onto a piece of gauze. In which order should the nurse perform the steps of pouring the solution? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

A nurse is caring for a client who is taking cimetidine. Which of the following client statements indicates to the nurse that the cimetidine treatment has been effective? (Select all that apply.)

A nurse is preparing a sterile field for the insertion of a urinary catheter. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)