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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Failure to engraft typically presents with symptoms such as persistent neutropenia, thrombocytopenia, and anemia, rather than skin peeling.
B. Veno-occlusive disease, also known as sinusoidal obstruction syndrome, can lead to liver dysfunction and subsequent skin manifestations such as peeling, especially on the palms and soles.
C. Graft-versus-host disease (GVHD) typically presents with symptoms such as skin rash, diarrhea, and liver dysfunction, but peeling skin is not a hallmark manifestation.
D. Pancytopenia refers to a deficiency of all types of blood cells (red blood cells, white blood cells, and platelets) and is not typically associated with skin peeling as a primary symptom.
Correct Answer is A
Explanation
A.
A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.
B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.
C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.
D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.
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