A nurse is caring for a patient in a long-term care facility who is receiving enteral feedings via an NG tube.
Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply)

Auscultate stomach sounds

Warm the formula to body temperature

Assist the client to sit in an upright position

Discard residual gastric contents

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

Auscultating stomach sounds is an important step before administering a tube feeding. This helps to ensure that the gastrointestinal system is functioning properly and can handle the feeding.

Choice B rationale

Warming the formula to body temperature can help to increase the comfort of the client during the feeding. However, it is not a necessary step and can be skipped if the client does not have a preference.

Choice C rationale

Assisting the client to sit in an upright position is crucial before administering a tube feeding. This position reduces the risk of aspiration, which can occur if the formula enters the lungs.

Choice D rationale

Discarding residual gastric contents is not recommended. Instead, the nurse should check for residual before the feeding, and if the volume is above the predetermined threshold, the feeding should be delayed and the healthcare provider notified.

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Correct Answer is C

Explanation

Platelet count is not the primary diagnostic test used to monitor the therapy’s effect of warfarin. Platelets are involved in the clotting process, but warfarin specifically works by inhibiting the synthesis of vitamin K-dependent clotting factors, which does not directly involve platelets.

Choice B rationale

The white blood cell count (WBC) is not used to monitor the effect of warfarin therapy. WBC is typically used to monitor for infection or inflammation, not the coagulation status of a patient.

Choice C rationale

Prothrombin time (PT) is the correct answer. Warfarin therapy is monitored using the PT, which is reported as the International Normalized Ratio (INR). Warfarin inhibits the synthesis of vitamin K-dependent clotting factors, which include Factors II, VII, IX, and X, and Proteins C and S. The PT/INR is sensitive to changes in these factors. An elevated INR indicates a higher risk of bleeding, while a lower INR suggests a higher risk of clotting.

Choice D rationale

Activated partial thromboplastin time (aPTT) is not typically used to monitor warfarin therapy. The aPTT test evaluates the intrinsic and common pathways of coagulation, which includes factors XII, XI, IX, VIII, X, V, II (prothrombin), and I (fibrinogen). Warfarin affects the extrinsic pathway and common pathway, not the intrinsic pathway. Therefore, aPTT is not the best test to monitor the effects of warfarin.

A. Decrease in systolic blood pressure B. Increase in saliva production C. Increase in percentage of body water D. Decrease in kidney function E. Decrease in kidney function

Correct Answer is D

Explanation

Choice A rationale

A decrease in systolic blood pressure is not a physiological change that increases the risk of dehydration in older adults.

Choice B rationale

An increase in saliva production does not occur with aging and does not increase the risk of dehydration.

Choice C rationale

An increase in the percentage of body water does not occur with aging. In fact, total body water decreases with age, which can contribute to an increased risk of dehydration.

Choice D rationale

A decrease in kidney function is a common physiological change that occurs with aging. This can lead to a decreased ability to concentrate urine and conserve water, increasing the risk of dehydration.

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A nurse is caring for a patient in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply)

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has a new prescription for warfarin. Which of the following diagnostic test results should the nurse use to monitor the therapy’s effect?

Correct Answer is C

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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A nurse is caring for a patient in a long-term care facility who is receiving enteral feedings via an NG tube.
Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply)