A nurse is assessing a client who is receiving enteral feedings via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?
Switch to a lactose-free formula.
Reposition the NG tube.
Increase the rate of formula delivery.
Add water to the formula.
The Correct Answer is D
A. Switch to a lactose-free formula – A lactose-free formula is necessary for clients with lactose intolerance but does not address the issue of hyperosmolar dehydration, which results from insufficient free water intake rather than intolerance to lactose.
B. Reposition the NG tube – Repositioning the tube is necessary if there is displacement, but it does not treat dehydration caused by hyperosmolar feedings.
C. Increase the rate of formula delivery – Increasing the rate can worsen dehydration by further increasing the solute load, leading to a greater fluid shift from intracellular to extracellular spaces.
D. Add water to the formula – This is the correct answer because hyperosmolar dehydration occurs when high-solute enteral formulas pull water into the intestines, leading to excessive fluid loss. To prevent this, the nurse should ensure the client receives adequate free water flushes alongside tube feedings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing.
B. Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus.
C. Frequent swallowing – This is the priority finding because it may indicate active bleeding at the surgical site. Children may not always report bleeding but may swallow frequently as blood drips into their throat. If left undetected, excessive bleeding can lead to hemorrhage and airway compromise. The nurse should inspect the throat immediately and notify the provider.
D. Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.
Correct Answer is D
Explanation
A. Place the client on an air mattress – While air mattresses help prevent pressure ulcers, they do not directly address mobility needs in the immediate postoperative period.
B. Rewrap the bandage every 8 hr in a circular pattern – The bandage should be reapplied more frequently (every 4–6 hr) using a figure-eight pattern to prevent restriction of circulation.
C. Turn the client every 4 hr while in bed – Clients should be turned at least every 2 hr to prevent pressure ulcers and improve circulation.
D. Instruct the client to use an overbed trapeze to move around in bed – This is the best intervention because it allows the client to reposition independently, reducing the risk of skin breakdown and enhancing mobility.
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