A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?

Confirm that bowel sounds are present.

Measure the client's total body weight.

Evaluate the client's ability to swallow.

Observe for signs of fluid volume deficit.

Answer and Explanation

The Correct Answer is A

Choice A reason: Before initiating tube feeding, it is crucial to ensure that the gastrointestinal system is functioning. The presence of bowel sounds indicates peristalsis, which is necessary for the digestion and absorption of the feeding.

Choice B reason: While measuring the client's total body weight is important for overall assessment and monitoring of nutritional status, it is not the most critical assessment before starting tube feeding.

Choice C reason: Evaluating the client's ability to swallow is not relevant in this scenario since the client will be receiving nutrition through a feeding tube due to malnutrition and dehydration.

Choice D reason: Observing for signs of fluid volume deficit is important, but the immediate concern before starting tube feeding is to confirm gastrointestinal activity through the presence of bowel sounds.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Choice A reason: False: Hand washing should be performed not only when exiting the client's room but also before entering the room and after any direct contact with the client or potentially contaminated surfaces within the room.

Choice B reason: True : The client has been diagnosed with Respiratory Syncytial Virus (RSV), which is a highly contagious virus. It can spread through droplets in the air when an infected person coughs or sneezes, or by touching a surface that has the virus on it. Therefore, contact and droplet precautions are necessary.

Choice C reason: True: Gowns and gloves should be worn whenever there is a potential for contact with secretions, especially when dealing with a patient who has a contagious condition like RSV. This is part of standard precautions to prevent the spread of infection.

Choice D reason: True: A mask should always be worn when in the client's room because RSV can be spread through droplets in the air. This is part of droplet precautions.

Choice E reason: True: This client would require a private room if admitted because RSV is highly contagious. Isolation in a private room is one of the strategies used to prevent the spread of the virus.

A. Skin turgor. B. Weight. C. Blood pressure. D. Lung sounds.

Correct Answer is B

Explanation

Choice A reason: Skin turgor is a method to assess hydration status, but it is not the most accurate indicator of fluid balance in a patient with fluid volume overload.

Choice B reason: Monitoring weight is the most accurate method to assess fluid balance. A sudden increase or decrease in weight is indicative of fluid changes.

Choice C reason: Blood pressure can be affected by fluid volume changes, but it does not provide a direct measure of fluid balance.

Choice D reason: Lung sounds can indicate fluid overload in the lungs but do not give a complete picture of overall fluid balance.

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A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

Correct Answer is B

Explanation

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