A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

The gastric residual volume is 250 mL following 2 hr of infusion.

The client is lying in a supine position.

The infusion pump for administering continuous feeding is turned off.

The enteral feeding bag and tubing are not dated.

Answer and Explanation

The Correct Answer is B

A. A gastric residual volume of 250 mL following 2 hours of infusion may indicate potential intolerance to the feeding, but it is not necessarily an immediate emergency unless it exceeds the facility’s threshold for residuals.
B. The client lying in a supine position poses a significant risk for aspiration, especially following a laryngectomy, where airway protection is compromised. Immediate intervention is necessary to reposition the client and reduce the risk of aspiration pneumonia.
C. While the infusion pump being off is concerning, it may not require immediate intervention as long as the nurse is aware and can address it promptly.
D. Not dating the enteral feeding bag and tubing is important for infection control; however, it does not require immediate intervention compared to the risk posed by a supine position.

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Correct Answer is B

Explanation

A. Delegating tasks to appropriate personnel is an important skill, but effective time management also involves personal task completion.

B. Completing activities for one client before moving to the next helps ensure tasks are not left incomplete and promotes organized workflow.

C. Focusing on objectives rather than just activities is a more comprehensive approach to time management, ensuring tasks align with goals.

D. Skipping break times can lead to burnout and decreased efficiency over time, rather than improving time management skills.

A. Justice B. Autonomy C. Nonmaleficence D. Veracity

Correct Answer is A

Explanation

A. Justice refers to fairness and equity in the distribution of resources and the treatment of

individuals. By spending an equal amount of time with each client regardless of their background or actions, the nurse is demonstrating the principle of justice.

B. Autonomy refers to respecting the right of individuals to make their own decisions about their healthcare. While important, it does not directly relate to the nurse's equal allocation of time.

C. Nonmaleficence refers to the duty to do no harm. While relevant to nursing care, it does not directly apply to the equal distribution of time among clients.

D. Veracity refers to truthfulness and honesty in communication. While important, it does not directly relate to the allocation of time among clients.

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A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

Nursing Test Bank

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