A nurse is caring for a client who has a gastrostomy tube and is receiving enteral nutrition. The nurse should identify that which of the following complications represents the greatest risk to the client?
Abdominal distention
Fluid overload
Glycosuria
Tube obstruction
The Correct Answer is D
Choice A reason: Abdominal distention is a possible complication of enteral nutrition, as it may indicate gas accumulation, constipation, or intolerance to the formula. However, it is not the greatest risk to the client, as it can be prevented or managed by adjusting the formula, rate, or volume of the feeding, or by administering medications or enemas.
Choice B reason: Fluid overload is a possible complication of enteral nutrition, as it may indicate excessive fluid intake, renal impairment, or heart failure. However, it is not the greatest risk to the client, as it can be prevented or managed by monitoring the fluid balance, electrolytes, and vital signs, or by administering diuretics or fluid restriction.
Choice C reason: Glycosuria is a possible complication of enteral nutrition, as it may indicate hyperglycemia, diabetes, or infection. However, it is not the greatest risk to the client, as it can be prevented or managed by monitoring the blood glucose, urine output, and signs of infection, or by administering insulin or antibiotics.
Choice D reason: Tube obstruction is the greatest risk to the client, as it may indicate clogging, kinking, or twisting of the tube, which can impair the delivery of the nutrition and medication, and cause aspiration, infection, or perforation. Tube obstruction can be prevented by flushing the tube with water before and after each feeding or medication, and by using a syringe or a pump to administer the formula. Tube obstruction can be managed by using warm water, carbonated beverages, or pancreatic enzymes to unclog the tube, or by replacing the tube if necessary.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice D reason:A metallic taste in the mouth is not a recognized symptom of hyperglycemia. It may occur in other conditions, such as certain medication side effects, infections, or metabolic disorders, but it is not specific to diabetes or high blood glucose levels. Including this as a sign of hyperglycemia could lead to confusion or misinterpretation of symptoms.
Choice A reason: Anxiety is not a specific symptom of hyperglycemia, although it can be associated with stress or other psychological factors that can affect blood sugar levels. Anxiety can also be a symptom of hypoglycemia, or low blood sugar, which requires immediate treatment.
Choice B reason: Hyperventilation, characterized by deep and rapid breathing, is a critical manifestation of severe hyperglycemia, particularly in cases ofdiabetic ketoacidosis (DKA). When blood glucose levels are extremely high, the body may produce ketones, leading to metabolic acidosis. To compensate, the client may developKussmaul respirations, a type of hyperventilation aimed at expelling excess carbon dioxide. This is a medical emergency and requires immediate intervention. Teaching the client to recognize hyperventilation as a sign of severe hyperglycemia is essential for timely treatment and prevention of complications.
Choice C reason: Cool skin is not a symptom of hyperglycemia, but rather a sign of poor circulation, which can be a complication of diabetes. Diabetes can damage the blood vessels and nerves that supply blood and oxygen to the skin, especially in the feet and legs. This can lead to skin problems, infections, and ulcers.
Correct Answer is C
Explanation
Choice A reason: The client should not replace salt with soy sauce, as soy sauce is not kosher. Soy sauce is made from fermented soybeans and wheat, which are not allowed in a kosher diet. The client should use kosher salt or other kosher seasonings instead.
Choice B reason: The client's primary vegetables should not be squash and corn, as they are not considered kosher. Squash and corn are classified as kitniyot, which are legumes, grains, seeds, and other plant products that are not allowed in a kosher diet. The client should eat more leafy greens, root vegetables, and fruits, which are kosher.
Choice C reason: The client can eat meat and nondairy margarine together, as they are both kosher. Nondairy margarine is made from vegetable oils, which are pareve, meaning they are neither meat nor dairy. The client should avoid eating meat and dairy products together, as they are not kosher.
Choice D reason: The client does not need to use their right hand when eating food, as this is not a requirement of a kosher diet. This is a practice of some Muslims, who believe that the right hand is for eating and the left hand is for cleaning. The client should follow the rules of kashrut, which are the Jewish laws of kosher food.
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