The nurse suspects that a patient who underwent esophageal surgery has a misplaced jejunostomy feeding tube. Which action would the nurse take?

Reinsert the tube

Reposition the tube

Document the findings and administer prescribed feedings

Notify the healthcare provider immediately

Answer and Explanation

The Correct Answer is D

Choice A reason: Reinserting the tube without confirming its correct placement can cause harm or lead to complications. It is not the nurse's role to reinsert the tube without proper verification.
Choice B reason: Repositioning the tube without verifying its placement could also cause harm. Ensuring correct placement should be done before any attempts to reposition the tube.
Choice C reason: Documenting the findings and administering feedings without confirming the tube's correct placement can result in serious complications, such as feeding into the wrong location.
Choice D reason: Notifying the healthcare provider immediately is the appropriate action. The provider can order verification of tube placement, such as through an X-ray, to ensure it is correctly positioned before any feedings are administered.

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Correct Answer is D

Explanation

Choice A reason: Adjusting the rate of the infusion or catheter drainage without first identifying the cause of the lack of drainage can be ineffective. It is essential to determine whether there is a physical obstruction before making rate adjustments.
Choice B reason: Irrigating the catheter might be necessary if there is a blockage, but it is not the first step. Checking the tubing for kinks should be done first to identify and correct any simple mechanical obstructions.
Choice C reason: Notifying the provider is important if the issue persists, but the nurse should first assess and try to resolve the problem by checking for any obvious causes like kinks in the tubing. Immediate provider notification is not the first action.
Choice D reason: Checking the tubing for kinks is the first and most logical step. Kinks in the catheter tubing can easily obstruct urine flow, and this simple assessment can quickly identify and resolve the issue, restoring proper drainage.

A. Reduce the client's intake of protein. B. Administer vitamin K. C. Restrict the client's intake of fluids. D. Administer diuretics.

Correct Answer is A

Explanation

Choice A reason: Reducing the client's intake of protein can help decrease the production of ammonia, which is a byproduct of protein metabolism. High ammonia levels contribute to hepatic encephalopathy, so a lower protein diet can be beneficial.
Choice B reason: Administering vitamin K is important for managing bleeding risks associated with cirrhosis, but it does not specifically address ammonia levels.
Choice C reason: Restricting fluid intake may be necessary for managing ascites and edema in cirrhosis but does not directly impact ammonia levels.
Choice D reason: Administering diuretics is often necessary to manage fluid retention and ascites, but it does not affect ammonia production or levels in the blood.

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The nurse suspects that a patient who underwent esophageal surgery has a misplaced jejunostomy feeding tube. Which action would the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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