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 A
Explanation
The correct answer is choice A. “Fish and poultry are primary sources of heme iron.”
Choice A rationale:
Fish and poultry are indeed primary sources of heme iron, which is the type of iron found in animal products.Heme iron is more easily absorbed by the body compared to non-heme iron, which is found in plant-based foods.
Choice B rationale:
Cooking in a stainless steel skillet does not significantly increase the amount of iron in the food.While cooking in cast iron skillets can add some iron to the food, stainless steel does not have the same effect.
Choice C rationale:
Drinking iced tea with meals can actually decrease the amount of iron absorbed.Tea contains tannins, which can inhibit the absorption of non-heme iron from plant-based foods.
Choice D rationale:
Drinking orange juice with iron supplements can actually increase absorption, not decrease it.Vitamin C, found in orange juice, enhances the absorption of non-heme iron.
Correct Answer is C
Explanation
The correct answer is choice c. Omega-3 fatty acids.
Choice A rationale:
Magnesium is generally abundant in a vegan diet, as it is found in many plant-based foods such as nuts, seeds, and leafy green vegetables.
Choice B rationale:
Vitamin A can be obtained from plant sources in the form of beta-carotene, which the body can convert into vitamin A. Therefore, vegans are not at high risk for vitamin A deficiency if they consume a variety of colorful fruits and vegetables.
Choice C rationale:
Omega-3 fatty acids are primarily found in fish and other seafood, which are not part of a vegan diet. While some plant-based sources like flaxseeds, chia seeds, and walnuts provide ALA (a type of omega-3), they may not be sufficient to meet the body’s needs for EPA and DHA, the more active forms of omega-3 fatty acids.
Choice D rationale:
Potassium is readily available in a wide range of fruits and vegetables, such as bananas, potatoes, and spinach, making it unlikely for vegans to be deficient in this nutrient.
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