A nurse is assessing a client who is receiving an intermittent enteral feed through a nasogastric tube. Which finding is the nurse's PRIORITY to address?

The client is reporting constipation.

The client reports being thirsty

The client is vomiting the enteral formula.

The client is experiencing abdominal cramping.

Answer and Explanation

The Correct Answer is C

A) The client is reporting constipation:

Constipation is a common issue with enteral feeding, often due to decreased fluid intake or lack of fiber. While it is important to manage constipation to improve comfort and bowel function, it is not as urgent as dealing with vomiting.

B) The client reports being thirsty:

Thirst can be a sign of dehydration or inadequate fluid intake. Although it should be addressed to ensure proper hydration, it is less critical compared to vomiting, which poses immediate risks.

C) The client is vomiting the enteral formula:

Vomiting is a priority concern because it can lead to aspiration, dehydration, electrolyte imbalances, and further complications. Addressing the cause of vomiting and managing it promptly is crucial for the client’s safety.

D) The client is experiencing abdominal cramping:

Abdominal cramping can be related to the feeding rate, type of formula, or intolerance. While it requires attention, it is less urgent than addressing vomiting, which could have more immediate and serious consequences.

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Correct Answer is B

Explanation

A) "Your daily intake of fats should be limited to no more than 35% of your daily caloric intake":

Current dietary guidelines typically recommend limiting fat intake to less than 30% of total daily calories, not 35%, for optimal heart health. This recommendation is slightly higher than what is generally advised for managing high cholesterol.

B) "You should avoid trans-fat as much as possible":

Trans fats significantly increase LDL cholesterol (bad cholesterol) levels and decrease HDL cholesterol (good cholesterol). Avoiding trans fats is crucial in managing high cholesterol and reducing cardiovascular risk, making this the most important recommendation.

C) "Your main sources of protein should be red meat":

Red meat, particularly processed red meat, is associated with higher cholesterol levels and cardiovascular risk. It is generally recommended to choose lean proteins, such as fish, poultry, and plant-based sources, over red meat.

D) "Fats provide the highest amount of energy per gram":

While fats do provide more energy per gram than carbohydrates or proteins, this statement does not directly address the management of cholesterol levels. The focus should be on the type of fats consumed rather than their energy content.

E) "Your intake of fats should be unsaturated fats":

While consuming unsaturated fats is beneficial, avoiding trans fats specifically addresses a more immediate concern for those with high cholesterol. Option B emphasizes the importance of eliminating harmful fats.

A. Constipation B. Polyuria C. EKG with a U wave D. Paresthesias of the extremities

Correct Answer is D

Explanation

A) Constipation: Elevated potassium levels (hyperkalemia) typically affect neuromuscular and cardiac function rather than gastrointestinal motility. Constipation is more commonly associated with conditions like hypokalemia or electrolyte imbalances affecting the gastrointestinal system.

B) Polyuria: Polyuria, or excessive urination, is not directly caused by hyperkalemia. It can occur due to conditions like diabetes mellitus or diabetes insipidus, or as a side effect of certain medications like diuretics. Hyperkalemia does not typically lead to increased urine output and may even lead to oliguria if severe renal impairment occurs.

C) EKG with a U wave: The presence of a U wave on an electrocardiogram (EKG) is typically associated with hypokalemia, not hyperkalemia. U waves are seen when potassium levels are low, reflecting delayed repolarization of the ventricles. In hyperkalemia, EKG changes more commonly include peaked T waves, prolonged PR interval, and widened QRS complexes.

D) Paresthesias of the extremities: Hyperkalemia can cause paresthesias, which are sensations of tingling or numbness, particularly in the extremities. This occurs due to the effect of elevated potassium levels on nerve and muscle function. As potassium is essential for maintaining normal neuromuscular function, deviations from normal levels can disrupt action potentials and lead to sensory disturbances like paresthesias.

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﻿A nurse is assessing a client who is receiving an intermittent enteral feed through a nasogastric tube. Which finding is the nurse's PRIORITY to address?

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