When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?

Monitor for hypertension

Measure residual every 24 hours

Check stools for diarrhea

Check blood glucose every 12 hours

Answer and Explanation

The Correct Answer is C

A)   Monitoring for hypertension is not directly related to caring for a client with enteral feeding via a jejunostomy tube.
B)   Measuring residual volume is a nursing intervention for clients with gastric feeding tubes, not jejunostomy tubes.
C)   Diarrhea is a potential complication of enteral feeding, and monitoring stool output is essential to assess for this complication and adjust feeding accordingly.
D)   Monitoring blood glucose levels is important for clients with diabetes but is not specific to caring for a client with enteral feeding via a jejunostomy tube.

Nursing Test Bank

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Correct Answer is D

Explanation

A) Requesting a dietary consult is useful but not the most immediate action needed.

B) Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance.
C) Fluid restriction may be considered but not before addressing the electrolyte issues.
D) Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.

A. WBC 10,000/mm3 (5,000-10,000 mm3) B. Serum potassium 3.5 mEq/L (3.5-5.0 mEq/L) C. Serum albumin 4.8 g/dL (3.5-5 g/dL) D. Lipase 900 u/L (20-180 u/L)

Correct Answer is D

Explanation

A) While an elevated WBC count may indicate infection, it is not unexpected in acute pancreatitis.
B) Serum potassium within normal range does not require immediate intervention.

C) Serum albumin within normal range does not require immediate intervention.

D) Lipase levels significantly elevated above the normal range indicate ongoing pancreatic inflammation and may require intervention or adjustment of treatment.

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When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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