A nurse is caring for a client who is receiving continuous feedings via NG tube. Which of the following actions should the nurse take?
Irrigate the client's tube with 10 ml of cool water every hr
Elevate the head of the client's bed to a 15 angle
Replace the client's feeding bag every 72 hr
Check the client's gastric residual every 4 hr.
The Correct Answer is D
A. Irrigate the client's tube with 10 ml of cool water every hr: Flushing an NG tube is appropriate to maintain patency, but 10 mL is often insufficient for continuous feedings, and routine irrigation “every hr” is not standard practice. Flushing should follow facility protocol and be based on feeding type, residuals, or signs of tube blockage.
B. Elevate the head of the client's bed to a 15 angle: Elevating the head of the bed only 15 degrees is insufficient to reduce the risk of aspiration during continuous enteral feeding. Evidence-based practice recommends elevating the head of the bed to 30–45 degrees to promote gastric emptying and prevent reflux or aspiration.
C. Replace the client's feeding bag every 72 hr: Feeding bags for continuous enteral feedings should be replaced more frequently, typically every 24 hours, to reduce bacterial contamination and the risk of infection. Waiting 72 hours increases the likelihood of microbial growth and potential sepsis.
D. Check the client's gastric residual every 4 hr: Monitoring gastric residuals every 4 hours is an important action to assess tolerance to continuous tube feeding. High residuals can indicate delayed gastric emptying or intolerance, guiding decisions to hold or adjust the feeding, preventing aspiration and other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A client who has a burn requiring a sterile dressing change: While burn care is important to prevent infection and promote healing, a dressing change is not immediately life-threatening. This task can be safely addressed after assessing clients with higher-priority acute risks.
B. A client who had an appendectomy 6 hr ago and has diminished bowel sounds: Diminished bowel sounds are common in the immediate postoperative period and do not usually indicate an emergent problem. This client requires ongoing monitoring, but there is no acute threat to life at this time.
C. A client who received a chemotherapy treatment and reports nausea: Nausea following chemotherapy is uncomfortable and should be managed promptly, but it is not immediately life-threatening. Interventions such as antiemetics can be provided after more urgent needs are addressed.
D. A client who has hypothyroidism and is stuporous: Stupor in a client with hypothyroidism may indicate myxedema or severe hypothyroid crisis, which can be life-threatening due to risk of respiratory depression, cardiovascular compromise, or altered mental status. This client requires immediate assessment and intervention, making them the highest priority.
Correct Answer is A
Explanation
A. Realign the extremity in traction: Muscle spasms can be caused by misalignment or improper positioning of the extremity. Realigning the leg ensures proper traction force distribution, reduces muscle tension, and alleviates pain. This is the most appropriate initial action for managing spasm-related discomfort.
B. Remove the traction weights: Removing weights would interrupt the prescribed traction, potentially worsening fracture alignment and increasing pain or complications. Traction must be maintained continuously unless ordered otherwise by the provider.
C. Increase the amount of traction: Increasing weight without a provider order can cause neurovascular compromise, worsen pain, or damage tissue. Adjustments to traction must be prescribed, not done autonomously by the nurse.
D. Allow the weights to rest on the floor: Letting the weights rest on the floor eliminates the traction force, which can lead to malalignment of the fracture, increased muscle spasms, and delayed healing. This action is unsafe and inappropriate.
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