A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

Report the findings to the healthcare provider.

Review the client's current electrolyte values.

Demonstrate the use of an incentive spirometer.

Connect the tube to low intermittent suction.

Answer and Explanation

The Correct Answer is A

A.   The development of a fever and dyspnea in a client receiving continuous tube feeding could indicate a serious complication, such as aspiration pneumonia, infection, or another significant issue. Reporting these findings to the healthcare provider is crucial for further assessment, diagnosis, and intervention.
B.   While monitoring electrolyte values is important in clients receiving tube feedings, especially if there are concerns about dehydration or imbalances, it is not the immediate priority in this scenario. The client's fever and dyspnea suggest an acute issue that needs prompt attention, and addressing the acute symptoms and reporting them to the healthcare provider takes precedence over reviewing electrolytes.
C.   An incentive spirometer is useful for improving lung function and preventing atelectasis, particularly in postoperative or immobile patients. However, the presence of fever and dyspnea could indicate a more urgent problem such as aspiration or infection, which requires immediate medical evaluation and intervention.
D.   Connecting the tube to low intermittent suction is typically used to decompress the stomach in cases of gastric distension or to prevent aspiration of gastrointestinal contents. However, in the context of the client's new onset of fever and dyspnea, this action does not directly address the potential underlying cause, which could be more serious.

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Correct Answer is A

Explanation

A.Potassium affects the electrical activity of the heart, and abnormal potassium levels can lead to serious cardiac arrhythmias or other complications. Continuous cardiac monitoring is crucial when administering potassium chloride because it helps detect any arrhythmias or changes in heart function that might be caused by changes in potassium levels.
B.Monitoring urinary output is important because adequate urine output helps assess kidney function and ensures that potassium is being excreted properly. While monitoring urinary output is important, it is secondary to immediate cardiac monitoring during the infusion.
C.Checking the serum potassium level after the infusion is important to confirm that potassium levels have normalized or stayed within the target range. However, this action is not as immediate as continuous cardiac monitoring during the infusion.
D.Regular monitoring of vital signs is important to assess overall client stability and detect any systemic changes. However, obtaining vital signs every 2 hours might not be as critical as continuous cardiac monitoring when administering potassium.

A. To administer a medication that is very irritating to the tissues. B. To administer a medication that requires use of an extra long needle. C. To follow the healthcare provider's prescription for Z track administration. D. To administer a large volume of medication.

Correct Answer is A

Explanation

A. The Z-track technique helps to prevent medication from leaking into the subcutaneous tissue and minimizes irritation by sealing the medication in the muscle. This is especially important for medications that are known to cause irritation or staining, such as iron supplements or some antipsychotics
B. The length of the needle is not directly related to the use of the Z-track technique. The Z-track method is used to minimize irritation and ensure that the medication is deposited in the muscle rather than leaking into the subcutaneous tissue.
C. The reason for using the Z-track technique is related to preventing irritation and ensuring proper medication delivery, rather than simply following a prescription.
D. The volume of medication is not the primary reason for using the Z-track technique. While the Z-track method can be used for administering larger volumes of medication, the technique's primary purpose is to prevent leakage and reduce tissue irritation.

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A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

Correct Answer is A

Explanation

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

Correct Answer is A

Explanation

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