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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A

Bananas are incorrect. While bananas contain some nutrients, they are not significant sources of vitamin D, calcium, or phosphate, which are key nutrients for preventing rickets.

Choice B

Apple juice is incorrect. Apple juice is not a significant source of vitamin D, calcium, or phosphate. It may contain some vitamins and minerals, but it is not a primary food source for preventing rickets.

Choice C

Oranges are incorrect. Like bananas and apple juice, oranges are not significant sources of vitamin D, calcium, or phosphate. While they contain vitamin C, which is important for overall health, they are not the best dietary source for preventing rickets.

Choice D

Fortified milk is correct. Rickets is a condition primarily caused by a deficiency of vitamin D, calcium, or phosphate. Vitamin D is crucial for the proper absorption of calcium and phosphorus in the body, which are essential for bone health and development. Fortified milk is an excellent dietary source for preventing rickets because it is often enriched with vitamin D and calcium, both of which are important for bone mineralization and growth.

A. Serum HDL (high-density lipoprotein) of 35 mg/dl (0.91 mmol/L). B. Serum HbA1c (glycosylated haemoglobin) of 4.8% (0.05). C. BMI (body mass index) of 22 kg/m2. D. Total serum calcium of 10 mg/dl (2.5 mmol/L).

Correct Answer is A

Explanation

Choice A

Serum HDL (high-density lipoprotein) of 35 mg/dL (0.91 mmol/L). Among the options provided, a serum HDL level of 35 mg/dL (0.91 mmol/L) is the assessment data that indicates the need for referral to a nutritionist. HDL is often referred to as "good" cholesterol because it helps remove excess cholesterol from the bloodstream, reducing the risk of cardiovascular disease. In this case, the HDL level of 35 mg/dL is below the recommended reference range for females (greater than 55 mg/dL or greater than 0.91 mmol/L), which could suggest a potential need for dietary and lifestyle interventions to improve cardiovascular health.

Choice B

Serum HbA1c (glycosylated haemoglobin) of 4.8% (0.05) is incorrect. This HbA1c level is within the normal reference range (4% to 5.9%) and indicates good blood sugar control.

Choice C

BMI (body mass index) of 22 kg/m² is incorrect. A BMI of 22 is within the normal weight range and might not necessarily indicate the need for a nutritionist referral.

Choice D

Total serum calcium of 10 mg/dL (2.5 mmol/L) is incorrect. This calcium level is within the normal reference range and might not require a nutritionist referral, unless there are other specific concerns related to calcium intake.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In conducting community health teaching, the nurse plans to describe foods that will help prevent rickets. What food product should the nurse recommend as the best dietary source for preventing rickets?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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