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 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.

A. Blood pressure 178/90 mm Hg B. Edema C. Bounding bilateral pulses D. Increased urine specific gravity

Correct Answer is D

Explanation

A) Blood pressure 178/90 mm Hg: Elevated blood pressure is more commonly associated with fluid overload or hypertension rather than dehydration. In dehydration, one would expect to see a decrease in blood pressure, particularly orthostatic hypotension, due to a reduction in blood volume.

B) Edema: Edema indicates fluid retention in the tissues, which is a sign of fluid overload rather than dehydration. Dehydration typically results in reduced extracellular fluid volume, leading to symptoms like dry mucous membranes and poor skin turgor, rather than swelling.

C) Bounding bilateral pulses: Bounding pulses are usually seen in conditions of increased cardiac output or fluid overload, where there is an excess of fluid volume. In contrast, dehydration often leads to weak and thready pulses due to decreased circulatory volume.

D) Increased urine specific gravity: Increased urine specific gravity is a direct indicator of dehydration. It occurs because the kidneys concentrate urine to conserve water, leading to a higher concentration of solutes in the urine. This is a reliable clinical marker of reduced hydration status, reflecting the body's attempt to maintain fluid balance by conserving water.

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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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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?