A nurse is assessing a client who is receiving intermittent enteral nutrition through a nasogastric tube. Which of the following assessments is the nurse's priority?
The client is reporting constipation.
The client reports being thirsty.
The client is experiencing abdominal cramping.
The client is regurgitating the enteral formula.
The Correct Answer is D
A. Constipation is a common but non-life-threatening side effect of enteral feeding and is not the priority.
B. Thirst indicates possible fluid imbalance but is not urgent compared to risk of aspiration.
C. Abdominal cramping can indicate intolerance to feeding but is not as immediately dangerous.
D. Regurgitating the enteral formula is the priority concern because it increases the risk of aspiration, which can lead to aspiration pneumonia—a life-threatening complication. This finding requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An INR of 5.2 is critically elevated and places the client at risk for spontaneous bleeding. This requires immediate provider notification and intervention.
B. A BUN of 21 mg/dL is slightly above the normal range (7–20 mg/dL) and is not immediately life-threatening.
C. A hemoglobin of 19 g/dL is elevated and may indicate dehydration or polycythemia, but it is not the most urgent value.
D. A fasting glucose of 69 mg/dL is slightly below normal but not critical and can typically be corrected with a snack or meal.
Correct Answer is ["0.3"]
Explanation
Order:Lidocaine 50 mg IV bolus
Supply:Lidocaine 200 mg/mL
Use the formula:
Volume to administer = Ordered dose ÷ Concentration available
Volume = 50 mg ÷ 200 mg/mL
Volume = 0.25 mL
Round to the nearest tenth: 0.3 mL
Final Answer:0.3 mL
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