A nurse is assessing a client who is receiving enteral feedings via ah NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?

Add water to the formula.

Reposition the NG tube.

Increase the rate of formula delivery.

Switch to a lactose-free formula.

Answer and Explanation

The Correct Answer is A

A. Adding water to the formula will decrease its osmolarity, reducing the risk of hyperosmolar dehydration. This action helps to dilute the formula and make it more isotonic, which is better tolerated by the client's gastrointestinal tract.
B. Repositioning the NG tube may be necessary if there are issues with tube placement or if the tube has migrated. However, it is not directly related to addressing hyperosmolar dehydration.
C. Increasing the rate of formula delivery may exacerbate hyperosmolar dehydration by introducing more concentrated formula into the gastrointestinal tract, leading to further dehydration.
D. Switching to a lactose-free formula may be appropriate if the client has lactose intolerance, but it does not address the issue of hyperosmolar dehydration. Adding water to the formula is the more appropriate intervention in this scenario to decrease osmolarity and prevent dehydration.

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Correct Answer is C

Explanation

A. Hazelnuts: While hazelnuts are a common allergen, they are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to hazelnuts is not necessary based solely on the child's latex allergy.
B. Almonds: Similar to hazelnuts, almonds are a common allergen but are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to almonds is not necessary based solely on the child's latex allergy.
C. Bananas: Bananas are one of the most common foods associated with latex allergy cross-sensitivity. Many individuals with latex allergy may also experience allergic reactions to bananas due to shared allergenic proteins. Therefore, further assessment for cross-sensitivity to bananas is warranted in this case.
D. Strawberries: While strawberries are a common allergen, they are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to strawberries is not necessary based solely on the child's latex allergy.

A. Changing the inner cannula on a tracheostomy B. Administering a platelet transfusion C. Irrigation of an external ear canal D. Inserting a tunneled central venous catheter

Correct Answer is D

Explanation

A. Changing the inner cannula on a tracheostomy: This procedure falls within the RN's scope of practice, as it involves basic tracheostomy care and maintenance, which nurses commonly perform.
B. Administering a platelet transfusion: Administering blood and blood products, including platelet transfusions, is within the RN's scope of practice, provided the nurse has appropriate training and competency.
C. Irrigation of an external ear canal: Irrigation of an external ear canal is a routine nursing procedure that falls within the RN's scope of practice, as long as it does not involve invasive procedures beyond irrigation.
D. Inserting a tunneled central venous catheter: Inserting tunneled central venous catheters is typically performed by advanced practice nurses or physicians with specific training and certification, such as nurse practitioners or interventional radiologists. This procedure is beyond the scope of practice for RNs and requires specialized skills and knowledge.

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A nurse is assessing a client who is receiving enteral feedings via ah NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?

Nursing Test Bank

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