A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

Temperature 38.2° C (100.8° F)

Hematocrit 45%

Respiratory rate 12/min

Urine specific gravity 1.015

Answer and Explanation

The Correct Answer is A

A.   This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B.   Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues

or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C.   A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D.   Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.

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Correct Answer is A

Explanation

A. Administering tube feedings while the client is in a supine (flat on their back) position can increase the risk of aspiration. Ideally, clients should be positioned upright or at a 30-45 degree angle during and after tube feedings to reduce the risk of reflux and aspiration.
B. Flushing the NG tube with tap water after feeding is just a standard practice to prevent clogging and maintain tube patency.

C. Administering tube feedings by gravity using a syringe barrel is an appropriate method. This allows for controlled and slow administration of the feeding solution, minimizing the risk of overfeeding or complications.
D. Aspirating gastric residual before initiating tube feedings is a standard practice to assess the amount of residual contents in the stomach. However, the amount of residual aspirate that warrants intervention can vary based on institutional policies and the client's condition.

A. To promote digestion B. To regulate blood pressure C. To reduce inflammation D. To enhance the immune system

Correct Answer is A

Explanation

A. Ginger is well-known for its ability to promote digestion. It can help alleviate nausea, improve gastric motility, and reduce bloating or discomfort associated with gastrointestinal issues such as a bowel obstruction. Therefore, the client's request for hot ginger tea likely aims to promote digestion, making option A a plausible choice.
B. Ginger is not typically used to regulate blood pressure. Its primary effects are related to digestion, anti- inflammatory properties, and potential immune system support, rather than directly affecting blood pressure regulation.
C. Ginger has anti-inflammatory properties, which can be beneficial in reducing inflammation in the body. However, in the context of the client's request for ginger tea after recovering from a bowel obstruction, the immediate purpose is more likely related to its digestive benefits rather than general anti- inflammatory effects.
D. Ginger has some antioxidant and immune-modulating properties that may contribute to enhancing the immune system. However, its use in Chinese culture, particularly as a tea, is traditionally more associated with digestive health rather than immune enhancement.

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A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

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Naxlex Comprehensive Predictor Exams

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?

Correct Answer is A

Explanation

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