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 D
Explanation
Choice A
Nuts is incorrect. Nuts are a good source of healthy fats, including monounsaturated and polyunsaturated fats, which can actually have a positive impact on heart health. They have been associated with improving HDL cholesterol levels and can be a part of a heart-healthy diet. While nuts are calorie-dense, small portions can be included as part of the client's diet to replace less healthy snacks. Therefore, nuts might not need to be completely avoided.
Choice B
Shellfish Is incorrect. Shellfish, including shrimp, crab, and lobster, are relatively low in saturated fat and cholesterol. While they do contain cholesterol, dietary cholesterol has less impact on blood cholesterol levels compared to saturated and trans fats. The client's main concern is elevated LDL cholesterol, which is influenced more by saturated fat intake. Therefore, avoiding shellfish might not be as crucial as focusing on saturated fat sources.
Choice C
Eggs is incorrect. Eggs are a source of dietary cholesterol, but they also provide essential nutrients. Recent research suggests that dietary cholesterol from foods like eggs has less impact on blood cholesterol levels for most people than was previously thought. For the client, the more significant concern is the elevated LDL cholesterol level. If the client enjoys eggs, they might not need to completely avoid them, but they should consume them in moderation and consider other dietary changes to reduce saturated fat intake.
Choice D
Cheese is correct. Cheese is often high in saturated fats, which can contribute to elevated LDL cholesterol levels. Therefore, it would be important for the client to limit their intake of high-fat cheeses.
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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