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 B
Explanation
This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the
patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.
For example:
Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.
Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.
Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.
Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:
- Hives: No hives or rashes on the skin are normal.
- Vomiting: No vomiting or nausea are normal.
- Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).
Correct Answer is B
Explanation
This needle size is appropriate for an intramuscular injection into the deltoid of a 175-pound adult male with a viscous fluid.
The needle length should be long enough to reach the muscle through the subcutaneous tissue, and the needle gauge should be suitable for the viscosity of the fluid. A 23-gauge needle is a common choice for intramuscular injections.
Choice A is wrong because a 1/2 inch needle is too short to reach the deltoid muscle in an adult male.
Choice C is wrong because a 1-1/2 inch needle is too long and may cause injury to the underlying nerves or blood vessels.
Choice D is wrong because a 16-gauge needle is too large and may cause excessive tissue trauma and pain.
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