A nurse is caring for a client on the medical surgical unit
Which of the following client findings suggest that the nurse should hold the tube feeding and notify the provider?
Gastric content pH
Abdominal findings
Oxygen saturation
Gastric residual
Blood glucose
Laboratory electrolyte levels
Correct Answer : B,D
A. Gastric content pH: The pH of the gastric aspirate increased from 4.8 to 6.4, which may indicate a change in gastric emptying or possible contamination with intestinal contents. However, a pH of 6.4 alone is not an immediate reason to hold enteral feeding unless accompanied by other concerning signs.
B. Abdominal findings: The client has a distended, firm, and tense abdomen, which may indicate intolerance to the tube feeding, delayed gastric emptying, or possible bowel obstruction. These physical findings require immediate attention because continuing enteral feeding could worsen complications such as vomiting, aspiration, or bowel perforation.
C. Oxygen saturation: The client’s oxygen saturation is 96% on room air, which is within normal limits. While hypoxia can be a sign of aspiration or respiratory compromise, the current oxygenation does not indicate an immediate need to hold feeding or notify the provider.
D. Gastric residual: A residual volume of 90 mL with a pH of 6.4 suggests delayed gastric emptying or intolerance of the feeding. High residuals increase the risk of aspiration and indicate that the client may not tolerate additional enteral nutrition. Holding the feeding and notifying the provider is warranted to prevent complications.
E. Blood glucose: The client’s blood glucose is slightly elevated at 152 mg/dL, which falls within the range for administering correctional insulin per provider orders. Although ongoing monitoring is important, this glucose level does not require holding the feeding.
F. Laboratory electrolyte levels: The client’s potassium (3.7 mEq/L) and sodium (137 mEq/L) are within normal limits. There are no electrolyte abnormalities that would necessitate holding the tube feeding at this time, though continued monitoring is important for ongoing nutritional support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Monitor for abdominal ascites: Clients with cirrhosis are at risk for fluid accumulation in the peritoneal cavity due to portal hypertension and hypoalbuminemia. Monitoring abdominal girth, weight, and signs of fluid retention is essential for early detection and timely intervention to prevent complications such as respiratory compromise or infection.
B. Implement a low-carbohydrate diet: Cirrhosis does not typically require a low-carbohydrate diet; instead, clients often need adequate calories and protein to prevent malnutrition. Restricting carbohydrates unnecessarily can worsen energy deficits and muscle wasting.
C. Review serum amylase levels: Serum amylase is primarily used to assess pancreatic function, not liver function. Liver disease monitoring focuses on liver enzymes (AST, ALT), bilirubin, and coagulation studies rather than amylase levels.
D. Place warm compresses on areas of pruritus: Pruritus in cirrhosis is better managed with cool baths, moisturizing creams, or medications like cholestyramine. Warm compresses can exacerbate itching by increasing skin blood flow and should generally be avoided.
Correct Answer is D
Explanation
A. Blood pressure 94/68 mm Hg: While slightly on the lower end for a 7-year-old, mild hypotension may not yet be present in severe dehydration because children often maintain blood pressure until significant fluid loss occurs. Blood pressure alone is not the earliest or most sensitive indicator of severe dehydration.
B. Urinary output 30 mL/hr: Normal urinary output for a child is approximately 1 mL/kg/hr. A child with severe dehydration typically has markedly reduced urine output (oliguria), so 30 mL/hr is still be within a low-normal range depending on the child’s weight
C. Respiratory rate 24/mn: This respiratory rate is within normal limits for a 7-year-old (approximately 18–25 breaths/min). It does not reflect compensation for dehydration or hypovolemia and is not a reliable indicator of severe fluid loss.
D. Heart rate 152/min: Tachycardia is an early and sensitive sign of hypovolemia in children. A heart rate of 152/min is significantly elevated for a 7-year-old, indicating compensatory mechanisms to maintain perfusion in response to severe dehydration.
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