A charge nurse is observing a nurse administer intermittent tube feedings via an NG tube to a client.
Which of the following actions by the nurse should prompt the charge nurse to intervene?
The nurse allows the client to rest in a supine position during feeding.
The nurse irrigates the NG tube with tap water after feeding.
The nurse administers the feeding through a syringe barrel by gravity.
The nurse initiates the feeding after aspirating 50 ml of gastric residual.
The nurse initiates the feeding after aspirating 50 ml of gastric residual.
The Correct Answer is A
Choice A rationale
Allowing the client to rest in a supine position during feeding should prompt the charge nurse to intervene. The client should be in an upright position during feedings and for an hour afterwards to prevent aspiration.
Choice B rationale
Irrigating the NG tube with tap water after feeding is a standard practice. This helps to keep the tube patent and prevent blockages.
Choice C rationale
Administering the feeding through a syringe barrel by gravity is a common method for giving intermittent tube feedings. This method allows for controlled administration of the feeding.
Choice D rationale
Initiating the feeding after aspirating 50 ml of gastric residual is a standard practice. Checking gastric residual volume before feedings helps to assess gastric emptying and tolerance to the feeding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Memory loss is not typically associated with inadequate dietary intake of fiber. Memory loss can be a symptom of various conditions such as Alzheimer’s disease, dementia, or certain vitamin deficiencies, but it is not directly linked to fiber intake.
Choice B rationale
Bleeding gums are not typically a symptom of inadequate dietary intake of fiber. Bleeding gums are more commonly associated with conditions such as gingivitis or vitamin C deficiency, not a lack of dietary fiber.
Choice C rationale
Constipation is the correct answer. Inadequate intake of dietary fiber can lead to constipation. Dietary fiber adds bulk to the diet and helps prevent constipation by promoting regular bowel movements.
Choice D rationale
Brittle hair is not typically a symptom of inadequate dietary intake of fiber. Brittle hair can be a sign of malnutrition or lack of certain nutrients like protein, but it is not directly linked to fiber intake.
Correct Answer is A
Explanation
Choice A rationale
An elevated white blood cell (WBC) count in a urinalysis can indicate an infection or inflammation in the body. A count of 10 is higher than the normal range, which is typically 0 to 5 WBCs per high power field.
Choice B rationale
Occasional casts in the urine are not typically a cause for concern. Casts are tiny tube-shaped particles that can form due to kidney conditions, but occasional casts can be normal.
Choice C rationale
A pH of 5.0 is within the normal range for urine pH, which is typically between 4.6 and 8.0.
Therefore, this result would not typically need to be communicated to the provider.
Choice D rationale
Dark amber color of the urine can be a sign of dehydration, but it can also be influenced by certain foods, medications, and health conditions. It is not typically a result that needs to be communicated to the provider.
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