A nurse is monitoring a client who has been receiving intermittent enteral feedings which of the following findings should the nurse identify as an indication of intolerance to the feeding?

Nausea

Urine output 40 m/hr

Soft stools

Headache

Answer and Explanation

The Correct Answer is A

A. Nausea: Nausea is a sign of intolerance to enteral feedings and may indicate delayed gastric emptying or feeding that is too rapid. The nurse should slow the rate of feeding, assess for abdominal distention, and check for residual volume.

B. Urine output 40 mL/hr: Urine output of 40 mL/hr is within the normal range (≥30 mL/hr) and does not indicate intolerance to enteral feedings. However, a significant decrease in urine output (oliguria) could indicate dehydration or kidney issues.

C. Soft stools: Soft stools can be a normal response to enteral feedings unless the client develops diarrhea. Watery, frequent stools may indicate malabsorption, but soft stools alone are not a sign of feeding intolerance.

D. Headache: Headaches are not a common symptom of enteral feeding intolerance. They may be related to other issues such as dehydration, hypertension, or medication side effects.

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Correct Answer is D

Explanation

A. “I'm sure your situation will get better with time." This response is dismissive and does not acknowledge the client’s feelings. It provides false reassurance rather than support.

B. "It must be terrible to be in this situation." While this statement attempts empathy, it may sound judgmental or patronizing rather than encouraging meaningful discussion.

C. "If I were you, I would talk with the hospital chaplain." This response assumes what the client should do rather than exploring their current coping mechanisms. It does not encourage self-reflection.

D. “Tell me what you have done in the past to cope with your problems.” This response uses therapeutic communication by allowing the client to reflect on past coping strategies and explore potential solutions.

A. "I can exercise as late as 1 hour before bedtime." B. "I should reduce my fluid intake 2 hours before bedtime." C. "I should take a 1 hour nap each day. D. "I can eat a large meal as late as 1 hour before bedtime."

Correct Answer is B

Explanation

A. "I can exercise as late as 1 hour before bedtime." Exercise close to bedtime can increase alertness and make it harder to fall asleep. It is recommended to finish exercising at least 3-4 hours before bedtime.

B. "I should reduce my fluid intake 2 hours before bedtime." Reducing fluid intake before bedtime helps minimize nocturia, which can disrupt sleep.

C. "I should take a 1-hour nap each day." Long or frequent naps can interfere with nighttime sleep. If naps are needed, they should be limited to 20-30 minutes earlier in the day.

D. "I can eat a large meal as late as 1 hour before bedtime." Eating a heavy meal before bed can cause discomfort and acid reflux, which may disrupt sleep. A light snack is preferable.

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A nurse is monitoring a client who has been receiving intermittent enteral feedings which of the following findings should the nurse identify as an indication of intolerance to the feeding?

Nursing Test Bank

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