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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A) They must also take a vitamin D supplement: Calcium absorption is highly dependent on vitamin D, which facilitates the absorption of calcium in the intestines. Taking a vitamin D supplement alongside calcium ensures effective utilization of calcium, improving bone health and preventing deficiencies.
B) Reduce sodium intake: While reducing sodium intake can benefit overall health and reduce fluid retention, it is not directly related to the absorption of calcium supplements. The focus should be on ensuring adequate vitamin D levels for proper calcium absorption.
C) Decrease the amount of fiber in your diet: High fiber diets do not necessarily hinder calcium absorption to a significant extent. In fact, maintaining a balanced diet with adequate fiber is important for overall health. Fiber does not need to be reduced specifically for better calcium absorption.
D) Take the medication with orange juice to increase absorption: Orange juice is high in vitamin C, which does not significantly impact calcium absorption. Calcium supplements are best taken with vitamin D or with meals to enhance absorption, rather than with orange juice alone.
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