A nurse is caring for a client who is receiving continuous enteral tube feeding and reports cramping and abdominal distention. Which of the following actions should the nurse take?
Apply low intermittent suction.
Increase the rate of the feeding.
Check for gastric residual.
Request a higher-fat formula.
The Correct Answer is C
Choice A rationale:
Applying low intermittent suction is used for nasogastric tube management to remove excess air or gastric contents and is not directly related to addressing cramping and abdominal distention. This action doesn't address the underlying issue.
Choice B rationale:
Increasing the rate of feeding is not the appropriate action to take in response to cramping and abdominal distention. It might worsen the discomfort and potentially overload the client's gastrointestinal system, leading to more issues.
Choice C rationale:
(Correct Choice) Checking for gastric residual is the appropriate action in this scenario. Cramping and abdominal distention can indicate delayed gastric emptying, which might be caused by an accumulation of feeding within the stomach. By checking for gastric residual, the nurse can assess whether there is a significant amount of residual feeding present, which might require adjusting the feeding rate or intervention.
Choice D rationale:
Requesting a higher-fat formula is not the initial action to take when the client reports cramping and abdominal distention. It assumes that the discomfort is due to the formula's composition, which might not be the case. First, assessing for gastric residual and considering other factors is important before changing the formula.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Avoiding glutamine is not a typical recommendation for managing Crohn's disease. Glutamine is an amino acid that plays a role in gut health, and its avoidance wouldn't necessarily aid in disease recovery.
Choice B rationale:
Limiting the amount of fiber in the diet is important for clients with Crohn's disease. High-fiber foods can exacerbate symptoms by causing bowel irritation and increasing motility. A low-fiber diet can help reduce inflammation and discomfort in the digestive tract.
Choice Crationale:
Taking mild laxatives is generally not recommended for individuals with Crohn's disease. Laxatives can irritate the digestive tract and potentially worsen symptoms. Bowel movements should be managed with dietary and lifestyle modifications under the guidance of a healthcare provider.
Choice Drationale:
It's not common for individuals with Crohn's disease to gain weight due to the disease itself. In fact, weight loss is a more typical symptom due to reduced nutrient absorption and increased metabolism.
Correct Answer is D
Explanation
Choice A rationale:
Canned potato soup is not a suitable choice for a heart-healthy diet. Canned soups often contain high levels of sodium, which can contribute to hypertension and worsen coronary artery disease.
Choice Brationale:
Baked ham is another poor choice for a heart-healthy diet. Processed meats like ham tend to be high in sodium, saturated fats, and preservatives, which can negatively impact cardiovascular health.
Choice Crationale:
Processed cheese is also not recommended for a heart-healthy diet. Processed cheese can be high in saturated fats and sodium, both of which are detrimental to cardiovascular health.
Choice D rationale:
The correct choice is broiled salmon. Salmon is rich in omega-3 fatty acids, which have been shown to have protective effects on the heart. Omega-3 fatty acids can help lower triglyceride levels, reduce inflammation, and improve overall cardiovascular health. Broiling the salmon is a heart-healthy cooking method that preserves its nutritional value without adding excessive unhealthy fats.
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