When entering a client's room, the nurse observes that the unlicensed assistive personnel (UAP) has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse?

The urine meter attached to the urinary drainage bag is completely full.

A feeding is infusing at 40 mL/hour through an enteral feeding tube.

There is a large dependent loop in the client's urinary drainage tubing.

Purulent drainage is present around the insertion site of the feeding tube.

Answer and Explanation

The Correct Answer is C

A. The urine meter attached to the urinary drainage bag is completely full. While this observation requires attention, it does not pose an immediate risk to the client's safety. The nurse should
empty the urine meter promptly to prevent overflow.

B.   A feeding is infusing at 40 mL/hour through an enteral feeding tube. This rate of infusion is within the typical range for enteral feedings and does not indicate an immediate safety concern. However, the nurse should assess the client's tolerance to the feeding.
C.   There is a large dependent loop in the client's urinary drainage tubing. A large dependent loop in the urinary drainage tubing can lead to urinary stasis and increase the risk of urinary tract
infections or catheter-associated complications. It requires immediate intervention to prevent complications.
D.   Purulent drainage is present around the insertion site of the feeding tube. While purulent drainage indicates a potential infection at the insertion site, it may not require immediate
intervention unless the client exhibits signs of systemic infection such as fever or increased white blood cell count.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Nutritional meal planning for older adults should only be planned by a dietitian. While a dietitian can provide valuable expertise in meal planning, it is not necessary for them to be the sole planner. Clients and their spouses can also learn and understand nutritional guidelines to plan meals effectively.
B. Socioeconomics should not be an issue in planning nutritional meals for older adults.

Socioeconomic factors can impact access to and affordability of nutritious foods, making them an important consideration in meal planning.
C. Dietary needs for older adults over and under age 70 are different. Nutritional needs may vary depending on factors such as age, health status, activity level, and underlying medical conditions. It's important for clients and their spouses to understand these differences to plan meals that meet individualized needs.

D. Age is not a factor in determining dietary needs for older adults. Age can indeed influence dietary needs, as nutritional requirements may change with aging, including considerations for maintaining muscle mass, bone health, and managing chronic conditions.

A. Determine pH value of specimen. B. Send fluid specimen to the laboratory. C. Withdraw the NGT and reinsert. D. Connect the NGT to wall suction.

Correct Answer is B

Explanation

A. Determine pH value of specimen. While pH testing can help confirm gastric placement of the NGT, the appearance of cloudy green fluid suggests a different issue that should be addressed first.
B. Send fluid specimen to the laboratory. Cloudy green fluid aspirated from the NGT suggests possible infection or contamination and should be sent to the laboratory for analysis to determine the presence of pathogens or other abnormalities.
C. Withdraw the NGT and reinsert. This may be necessary if placement is incorrect, but the cloudy green fluid suggests a potential issue beyond placement.
D. Connect the NGT to wall suction. Suctioning should not be initiated until the nature of the aspirated fluid is determined. If the fluid is infected, suctioning it could spread pathogens or cause further complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When entering a client's room, the nurse observes that the unlicensed assistive personnel (UAP) has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is helping develop a meal plan based on nutritional guidelines for an older adult client being discharged to home with the client's spouse. Which statement by the client and spouse best indicates an understanding of the nutritional guidelines when planning meals?

Correct Answer is C

Explanation

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

Correct Answer is B

Explanation

A middle-aged client newly diagnosed with cholelithiasis is choosing the evening meal from the menu. Which food choice should the nurse advise the client to omit?

A client has a serum sodium level of 155 mEq/L (155 mmol/L). The nurse should encourage the client to make which selection from the lunch menu? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

A malnourished child is receiving several nutritional supplements. Which statement by the child indicates that an adequate amount of Vitamin A is being provided?

A medication that causes extreme photosensitivity was recently prescribed for a client. In providing discharge instructions, the nurse should teach this client to increase intake of which foods?

A client is receiving total parenteral nutrition (TPN) via a subclavian central line, and the solution bag is nearly empty. The next bag of TPN is not available from the pharmacy. Which action should the nurse implement until the fluid arrives?

The nurse is planning a nutrition class for vegans. Which food should the nurse encourage to be combined with other foods to enhance the nutritional intake in the vegan diet?

Which meal selection by a client who is lacto-ovo-vegetarian indicates to the nurse that the client understands the use of complete proteins in the diet?