A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?

Label the feeding bag with the date and time of the start of the feeding.

Aspirate the client's stomach contents.

Hang the feeding bag 30 cm (12 inches) above the client.

Warm the feeding to room temperature.

Answer and Explanation

The Correct Answer is B

Choice A reason:Labeling the feeding bag with the date and time is important for tracking, but it is not the first action to take. The priority is to ensure that the NG tube is correctly placed and the stomach contents can be aspirated to verify placement before administering the feeding.

Choice B reason:Aspirating the client's stomach contents is the first action the nurse should take. This is to confirm the correct placement of the NG tube to prevent complications such as aspiration pneumonia. It is a critical step before starting any enteral feeding.

Choice C reason: Hanging the feeding bag 30 cm (12 inches) above the client is necessary for gravity feeding, but it comes after verifying the NG tube placement through aspiration of stomach contents.

Choice D reason:Warming the feeding to room temperature is a comfort measure and helps to prevent gastrointestinal discomfort. However, it is not the first action to take. The priority is to check the tube placement.

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Correct Answer is B

Explanation

Choice A reason:Bubbling in the water seal chamber with exhalation can be normal, indicating that air is being evacuated from the pleural space.

Choice B reason:Crepitus, or subcutaneous emphysema, can indicate that air is leaking into the tissue around the chest tube site, which is a serious complication that requires immediate attention.

Choice C reason:

Movement of the trachea toward the unaffected side can indicate tension pneumothorax, a life-threatening condition that also requires immediate attention.

Choice D reason:If the eyelets of the chest tube are not visible, it may simply mean that the tube is inserted fully, which is not an immediate cause for concern unless other symptoms are present.

A. Asterixis B. Change in orientation C. Anorexia D. Ascites E. Fetor hepaticus

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Asterixis, also known as "liver flap," is a tremor of the hand when the wrist is extended, often seen in hepatic encephalopathy as a result of altered brain function.

Choice B reason: A change in orientation, including confusion and altered consciousness, is a hallmark of hepatic encephalopathy, reflecting the brain's impaired ability to process information.

Choice C reason: Anorexia may be present in cirrhosis, but it is not a specific indicator of hepatic encephalopathy.

Choice D reason: Ascites is a common complication of cirrhosis due to portal hypertension but is not a direct indicator of hepatic encephalopathy.

Choice E reason: Fetor hepaticus, a musty odor of the breath, is a distinctive symptom of hepatic encephalopathy caused by the presence of mercaptans in the breath as the liver fails to break down sulfur-containing amino acids.

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A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider immediately?

Correct Answer is B

Explanation

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Correct Answer is ["A","B","E"]

Explanation

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