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 B
Explanation
Choice A
Advising the client that too much fruit can irritate the colon is not the right choice. While it's true that excessive consumption of certain fruits can cause gastrointestinal discomfort, this information is not directly related to celiac disease or the selected meal.
Choice B
Informing the client that oatmeal contains gluten is the right choice. Celiac disease is an autoimmune disorder in which consuming gluten, a protein found in wheat, rye, and barley, triggers an immune response that damages the small intestine. Oatmeal itself is naturally gluten-free, but it is often processed in facilities that also process gluten-containing grains, which can lead to cross-contamination. Therefore, it's important for individuals with celiac disease to choose certified gluten-free oats to avoid adverse reactions.
Choice C
Commending the client for selecting fat-free milk is not the best choice. While choosing a healthier milk option is beneficial for overall health, it is not the most important action in this situation, considering the client's celiac disease.
Choice D reason;
Encouraging the client to choose decaffeinated coffee is not the right choice. The choice of caffeinated or decaffeinated coffee is a matter of preference and is not directly related to celiac disease or the potential for gluten exposure from the oatmeal.
Correct Answer is A
Explanation
Choice A
Body mass index (BMI) of 17 is the correct finding. A low Body Mass Index (BMI) is a common indicator of malnutrition. BMI is a measurement that considers a person's weight in relation to their height. A BMI of 17 suggests that the person is underweight, which can be indicative of malnutrition. Malnutrition is characterized by inadequate intake of calories, protein, vitamins, and minerals that are essential for maintaining health and well-being.
Choice B
Decrease in appetite is not correct finding. While a decrease in appetite might contribute to malnutrition, it's a symptom rather than a definitive indicator.
Choice C
Dry mucosal membranes are not the correct finding. Dry mucosal membranes can be related to dehydration or other conditions, but they are not specific enough to confirm malnutrition on their own.
Choice D
Weight of 227 pounds (103 kg) is not the correct finding. This weight is not necessarily indicative of malnutrition on its own. It's important to consider the individual's height, BMI, and other factors when assessing malnutrition.

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