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.
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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Related Questions
Correct Answer is D
Explanation
A. Dependent edema may be present in pericarditis but is not typically the priority finding unless it indicates worsening heart failure.
B. Pericardial friction rub is a classic finding in pericarditis but is not the priority unless it indicates cardiac tamponade, which is a medical emergency.
C. Paradoxical pulse may occur in pericarditis but is not necessarily the priority finding unless it is severe and indicative of cardiac tamponade.
D. Substernal chest pain is the priority finding in pericarditis as it indicates inflammation of the pericardium, which can lead to complications such as myocardial infarction or cardiac
tamponade. Prompt intervention is necessary to alleviate pain and prevent complications.
Correct Answer is D
Explanation
A. A client who is 3 hr post Foley catheter removal and has not voided - While this may require assessment, it is not as urgent as assessing a client with potentially significant respiratory complications.
B. A client who is 3 days postoperative colectomy with a large, loose melena stool - While melena may indicate gastrointestinal bleeding, the client is not actively experiencing a respiratory issue.
C. A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 - Pain is important to address, but it is not as urgent as respiratory distress.
D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - Pink-tinged sputum may indicate bleeding from the respiratory tract, which could be a complication of the procedure and requires immediate assessment and intervention.
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