A client is receiving a continuous gastric tube feeding at 80 mL/hour. The nurse records the client's gastric residual volume as 325 mL during each of two consecutive hourly measurements. What assessment should the nurse complete before contacting the healthcare provider?
Observe for abdominal distention,
Calculate 24-hour caloric intake.
Measure the urinary output.
Check for body weight changes.
The Correct Answer is A
Choice A
Observing for abdominal distention is recommended. Gastric residual volume (GRV) is the amount of formula or food remaining in the stomach after a feeding through a gastric tube. A GRV of 325 mL is relatively high, and it's important to assess the client for signs of potential complications before contacting the healthcare provider. Observe for signs of abdominal distention, which could indicate that the stomach is not adequately emptying or that the feeding is not being tolerated well.
Choice B
Calculating 24-hour caloric intake is not recommended: While monitoring caloric intake is important for overall nutritional assessment, it does not address the immediate concern of a high GRV and the potential need for adjustment of the feeding rate or management.
Choice C
Measuring urinary output is not recommended: Urinary output is important to monitor for fluid balance, but it may not be directly related to the elevated GRV.
Choice D
Checking for body weight changes is not recommended: Monitoring body weight is essential for assessing nutritional status, but it may not provide immediate insights into the impact of the elevated GRV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A
Grilled salmon is correct. Salmon is a good source of protein and healthy omega-3 fatty acids. Protein is essential for wound healing and tissue repair, while omega-3 fatty acids have anti-inflammatory properties that can help with the healing process.
Choice B
Soda crackers is incorrect. Soda crackers are not particularly nutrient-dense and may not contribute significantly to postoperative healing. While they might be a bland option for settling the stomach, they do not offer the same nutritional benefits as the other selected options.
Choice C
Scrambled eggs are correct. Eggs are a good source of high-quality protein and contain essential nutrients like vitamin D and choline. Protein is crucial for tissue repair and recovery, and vitamin D supports bone health.
Choice D
Baked chicken is correct: Lean protein sources like baked chicken are important for wound healing and maintaining muscle mass. Protein helps the body repair and build new tissues.
Choice E
Flavoured gelatine is correct. Flavoured gelatine can be a soft and easily digestible source of hydration and calories. It's also a good option for someone recovering from surgery as it provides some energy and can be gentle on the digestive system.
Correct Answer is C
Explanation
Choice A
Coffee is incorrect. Coffee can inhibit iron absorption and is not a good choice for increasing iron intake.
Choice B
Hot tea is incorrect. Similar to coffee, some compounds in tea can interfere with iron absorption, making it less optimal for increasing iron intake.
Choice C
Orange juice is correct. Orange juice is a great choice as it is high in vitamin C, which can enhance the absorption of iron from plant-based sources like oatmeal. The vitamin C in orange juice helps convert non-heme iron into a form that is more easily absorbed by the body.
Choice D
Apple juice is incorrect. While apple juice is a source of fluids, it doesn't provide the same level of vitamin C as orange juice, which is important for enhancing iron absorption.
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