A nurse is administering an intermittent enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take?
Replace the NG tube.
Lower the head of the bed to 15°.
Slow the rate of formula instillation.
Chill and readminister the formula.
The Correct Answer is C
A. Replace the NG tube.: There is no indication that the NG tube is malfunctioning or misplaced in this case. The cramping and nausea are more likely related to the feeding itself, not the tube.
B. Lower the head of the bed to 15°.: Lowering the head of the bed would increase the risk of aspiration. The head of the bed should be elevated during enteral feeding to reduce this risk.
C. Slow the rate of formula instillation.: Abdominal cramping and nausea during enteral feeding can occur if the feeding rate is too fast. Slowing the rate allows the stomach to better tolerate the formula and can alleviate symptoms.
D. Chill and readminister the formula.: The temperature of the formula should not cause the cramping or nausea. Feeding should be administered at room temperature or as directed by protocol, and re-chilling it is unlikely to help with the symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. You wish you were no longer alive?: This response might sound accusatory and may invalidate the client's feelings. The nurse should express empathy and understanding instead of making the client feel misunderstood.
B. "It is common for people who have a terminal illness to feel that way.": This response validates the client's feelings by acknowledging the emotional distress that often accompanies a terminal illness. It normalizes the experience without minimizing it and opens the door for further discussion.
C. "Why do you wish you weren't alive any longer?": While this response is direct, it might sound too probing and may feel intrusive or dismissive of the client's emotional state. A softer, more empathetic approach is usually preferred.
D. "We should talk about the treatment plan your provider has suggested.": While discussing treatment plans is important, this response may deflect the client's emotional distress and shift the focus away from their immediate emotional needs. The nurse should first address the emotional aspect before discussing treatment.
Correct Answer is D
Explanation
A. "My child still wets the bed at least two times per week." While this is a concern, bedwetting can be a normal developmental behavior for children at this age and does not necessarily indicate a problem unless it persists beyond the typical age range.
B. "I have a difficult time getting my child to eat green vegetables." This is a common concern for parents of young children and typically does not warrant immediate attention, although it may require guidance on healthy eating habits.
C. "My child continually asks me the same questions." Repetition of questions is a normal part of cognitive development in young children and does not indicate an issue by itself.
D. "I have noticed that my child is withdrawn since we switched day care providers." This is the priority concern. Withdrawal or behavioral changes, particularly after a significant event like a change in day care, can indicate stress, anxiety, or possible emotional issues, and the nurse should address this promptly to ensure the child's well-being.
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