Which symptom experienced by a client receiving a continuous enteral feeding via a nasogastric tube requires priority follow-up by the nurse?
The client has frequent coughing spells.
The client reports mild abdominal cramps.
The client has high-pitched bowel sounds.
The client reports one to two soft bowel movements per day.
The Correct Answer is A
This is because coughing can indicate aspiration of the feeding into the lungs, which can lead to pneumonia and other serious complications. Aspiration is reported in up to 89% of patients receiving nasogastric tube feeding.
Therefore, the nurse should prioritize assessing the client for signs of aspiration and ensuring proper tube placement.
Choice B is wrong because mild abdominal cramps are a common side effect of nasogastric tube feeding and do not require immediate intervention unless they are severe or persistent.
Choice C is wrong because high-pitched bowel sounds are normal and indicate peristalsis and digestion.
They do not indicate a problem with the tube feeding.
Choice D is wrong because one to two soft bowel movements per day are desirable and indicate adequate nutrition and hydration.
They do not indicate a problem with the tube feeding.
Normal ranges for gastric residual volume are less than 200 mL for adults and less than 100 mL for children. Normal ranges for pH of gastric aspirate are 1 to 5.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The first observation the nurse should perform for a client who is receiving from the post anesthesia unit after a colon resection is to assess the patency of the airway and respiratory function.
This is because the airway is the most vital for the survival of the client and any compromise can lead to hypoxia and death.
The nurse should then take vital signs, check the wound dressing, and assess the foley catheter drainage.
Choice A is wrong because the client’s wound dressing is not as important as the airway and can be checked later.
Choice B is wrong because the client’s level of consciousness may be affected by the anesthesia and is not a priority over the airway.
Choice D is wrong because the client’s foley catheter drainage is not a critical observation and can be monitored later.
Normal ranges for respiratory rate are 12 to 20 breaths per minute for adults, oxygen saturation is 95% to 100%, and blood pressure is 120/80 mmHg for healthy individuals.
Correct Answer is D
Explanation
Insulin regular (Humulin-R) is the only form of insulin that is safe for intravenous administration. This is because it is a short-acting insulin that has a rapid onset and peak time, and does not contain any additives or suspensions that could interfere with the infusion.
Choice A is wrong because insulin aspart (Novo Log) is a rapid-acting insulin that is usually taken right before a meal. It is not suitable for intravenous use because it has a different amino acid sequence than human insulin.
Choice B is wrong because insulin glargine (Lantus) is a long-acting insulin that covers insulin needs for about a full day. It is not suitable for intravenous use because it forms micro-precipitates under the skin that release insulin slowly and steadily.
Choice C is wrong because insulin lispro (Humalog) is a rapid-acting insulin that is usually taken right before a meal. It is not suitable for intravenous use because it has a different amino acid sequence than human insulin.
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