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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","F"]
Explanation
Choice A: Administer antiemetics as needed Reason: Acute pancreatitis often causes severe nausea and vomiting. Antiemetics are administered to control these symptoms and prevent further complications such as dehydration and electrolyte imbalance.
Choice B: Administer analgesics as needed Reason: Pain management is a crucial part of the treatment for acute pancreatitis. The condition can cause severe abdominal pain, and analgesics are administered to provide relief.
Choice C: NPO (nothing by mouth) until pain-free Reason: The goal in treating acute pancreatitis is to allow the pancreas to rest and recover from the inflammation3. Keeping the patient NPO (nothing by mouth) helps achieve this by reducing the stimulation and workload of the pancreas.
Choice D: Monitor blood glucose and provide insulin as needed Reason: Acute pancreatitis can affect the pancreas’ ability to produce insulin, leading to elevated blood glucose levels. Therefore, monitoring blood glucose levels and administering insulin as needed is an important part of the management plan.
Choice E: Side-lying or fetal position Reason: While the side-lying or fetal position might help some patients with abdominal pain, it is not a standard intervention for acute pancreatitis. Therefore, this option is not correct.
Choice F: Monitor hydration status Reason: Patients with acute pancreatitis are at risk of dehydration due to symptoms like vomiting and decreased oral intake. Monitoring hydration status is crucial to ensure appropriate fluid replacement.
Correct Answer is ["167"]
Explanation
- Step 1: Identify the client's weight in pounds. The client weighs 245 lbs.
- Step 2: Convert the client's weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, 245 lbs = 245 ÷ 2.2 kg. Calculating the division gives us approximately 111.36 kg.
- Step 3: Identify the prescribed dose in mg/kg. The client is scheduled to receive 1.5 mg/kg of enoxaparin.
- Step 4: Calculate the total dose in mg. We can do this by multiplying the client's weight in kg by the prescribed dose in mg/kg:
- Total dose = 1.5 mg/kg × 111.36 kg.
- Calculating the multiplication gives us approximately 167.04 mg.
- Step 5: Round the total dose to the nearest whole number. Rounding 167.04 gives us 167.
administer 167 mg of enoxaparin per dose.
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