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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Emptying the appliance daily at bedtime is not frequent enough to prevent leakage and ensure comfort, especially if the bag fills up during the day or night.
Choice B reason: Emptying the appliance twice a day may not be sufficient, depending on the amount of urine output. It could lead to overfilling and leakage.
Choice C reason: Waiting until the bag is full can increase the risk of leakage and discomfort. It is essential to empty the bag before it gets too full.
Choice D reason: Emptying the appliance when it is 2/3 full is the recommended practice. This prevents overfilling, reduces the risk of leakage, and ensures the client's comfort and hygiene.
Correct Answer is D
Explanation
Choice A reason: Including foods high in fiber can be beneficial for overall digestive health, but it is not specifically targeted to managing biliary colic from chronic cholecystitis. The key dietary focus for these patients is to manage fat intake rather than fiber.
Choice B reason: Including foods high in starch and proteins does not directly address the dietary needs for managing biliary colic. While proteins and starches are part of a balanced diet, the critical factor for these patients is fat consumption.
Choice C reason: Avoiding foods high in sodium is generally good advice for cardiovascular health and can help reduce the risk of hypertension, but it is not specifically related to managing biliary colic.
Choice D reason: Avoiding foods high in fat is crucial for patients with chronic cholecystitis. High-fat foods can trigger biliary colic by stimulating the gallbladder to release bile, which can be painful when the bile ducts are inflamed or obstructed.
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