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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Calcium is not a dietary supplement that can help with wound healing, although it is important for bone health and muscle contraction. Calcium deficiency can cause osteoporosis, muscle cramps, and abnormal heart rhythms, but it does not affect wound healing.
Choice B reason: Potassium is not a dietary supplement that can help with wound healing, although it is essential for nerve and muscle function and fluid balance. Potassium deficiency can cause weakness, fatigue, arrhythmias, and muscle cramps, but it does not affect wound healing.
Choice C reason: Vitamin C is a dietary supplement that can help with wound healing, as it is involved in collagen synthesis, tissue repair, and immune response. Vitamin C deficiency can cause scurvy, which is characterized by bleeding gums, poor wound healing, and anemia.
Choice D reason: Vitamin D is not a dietary supplement that can help with wound healing, although it is necessary for calcium absorption, bone health, and immune function. Vitamin D deficiency can cause rickets, osteomalacia, and increased risk of infections, but it does not affect wound healing.
Correct Answer is D
Explanation
Choice A reason: Green tea is not a beverage that enhances the absorption of nonheme iron, but rather inhibits it. Green tea contains tannins, which are compounds that bind to iron and prevent its absorption. The nurse should advise the client to avoid drinking green tea or other beverages that contain tannins, such as black tea, with meals that contain iron.
Choice B reason: Coffee is not a beverage that enhances the absorption of nonheme iron, but rather inhibits it. Coffee also contains tannins, as well as caffeine, which can interfere with iron absorption. The nurse should recommend the client to limit or avoid coffee intake, especially with iron-rich foods.
Choice C reason: Milk is not a beverage that enhances the absorption of nonheme iron, but rather inhibits it. Milk contains calcium, which can compete with iron for absorption. The nurse should suggest the client to consume milk and other dairy products separately from iron-containing foods.
Choice D reason: Orange juice is a beverage that enhances the absorption of nonheme iron, as it is rich in vitamin C. Vitamin C can increase the absorption of nonheme iron by converting it from the ferric form to the more absorbable ferrous form. The nurse should encourage the client to drink orange juice or other citrus juices with meals that contain iron.
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