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A nurse is caring for a client who is receiving enteral feeding.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

Day 1:

The client is receiving intermittent tube feedings via an NG tube. Abdomen is soft, nondistended.

pH of gastric aspirate 3.0

Gastric residual volume 30 mL

Abdominal girth at umbilicus 96.5 cm (38 in)

Day 3:

Abdomen is distended. Client reports nausea.

pH of gastric aspirate 4.0

Gastric residual volume 620 mL

Abdominal girth at umbilicus 101 cm (39.8 in)

Diagnostic Results

Day 1:

Casual glucose 155 mg/dL (less than 200 mg/dL)

Flat plate of abdomen: tip of NG tube in stomach

Day 3:

Casual glucose 275 mg/dL (less than 200 mg/dL)

pH of gastric aspirate 3.0

Gastric residual volume 30 mL

Abdominal girth at umbilicus 96.5 cm (38 in)

Abdomen is distended. Client reports nausea.

Gastric residual volume 620 mL

Abdominal girth at umbilicus 101 cm (39.8 in)

Casual glucose 275 mg/dL (less than 200 mg/dL)

Answer and Explanation

The Correct Answer is ["D","E","F","G"]

• Abdomen distended: Abdominal distention is a sign of impaired gastric emptying or intolerance to enteral feeding. The increase from 96.5 cm to 101 cm indicates accumulation of gastric contents, which can lead to vomiting, aspiration, or discomfort. Prompt follow-up is required to evaluate feeding tolerance and adjust the enteral regimen.

• Nausea: Nausea in a client receiving enteral feeding can indicate delayed gastric emptying, overfeeding, or potential obstruction. Coupled with abdominal distention and high residual volumes, it suggests intolerance to the current feeding schedule or formula. Immediate assessment is necessary to prevent complications like aspiration.

• Gastric residual volume 620 Ml: A gastric residual volume over 500 mL is considered critically high and indicates severe delayed gastric emptying. High residuals increase the risk of aspiration pneumonia and require holding or adjusting the feeding, notifying the healthcare provider, and assessing for gastrointestinal complications.

• Casual glucose 275 mg/dL: A glucose of 275 mg/dL exceeds the desired limit for a client receiving enteral feeding. Hyperglycemia can result from high-calorie formulas, underlying diabetes, or stress response. Persistent hyperglycemia increases the risk of infection, delayed wound healing, and other complications, warranting immediate follow-up and possible insulin therapy adjustments.

• Abdominal girth at umbilicus 101 cm (39.8 in): An increase in abdominal girth from 96.5 cm to 101 cm, combined with a report of nausea, confirms that the gastrointestinal tract is not processing the intermittent feedings, possibly due to a paralytic ileus or delayed gastric emptying.

Rationale for incorrect choices

• pH of gastric aspirate 3.0: The pH of gastric aspirate within this range reflects acidic gastric contents, which is expected and does not indicate immediate complications. While pH monitoring is important for verifying tube placement, these values do not require urgent follow-up.

• Abdominal girth 96.5 cm: The initial abdominal girth is within normal limits and shows no signs of distention. This is a baseline measurement and does not indicate intolerance to feeding, so it does not require immediate follow-up.

• Gastric residual volume 30 mL: A low residual volume indicates good gastric emptying and feeding tolerance. No urgent action is necessary for this finding and it reflects proper enteral nutrition management.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Perform the intramuscular (IM) injections slowly: Rapid injection can increase pain and tissue trauma, but slowing the injection alone is not the primary evidence-based strategy for minimizing pain in pediatric vaccinations. Other interventions, such as topical anesthetics or distraction techniques, are more effective in reducing procedural pain.

B. Apply a topical anesthetic: Topical anesthetics, such as lidocaine-prilocaine cream, are recommended for children to numb the injection site before IM vaccinations. Applying the anesthetic 30–60 minutes prior to the injection decreases pain and anxiety, improves cooperation, and supports a positive vaccination experience, making it an essential measure.

C. Place client in supine position: For IM injections, children older than infants are typically seated upright or held securely by a caregiver to allow proper access to the injection site and reduce fear. Supine positioning is less appropriate for a 5-year-old and may increase distress rather than improve safety or comfort.

D. Inject the most painful vaccine first: Evidence suggests that administering the least painful vaccine first can reduce overall distress, as children experience less anticipatory anxiety. Giving the most painful injection first may increase fear and resistance to subsequent injections, making it a less effective strategy for managing procedural pain.

A. Drug preparation error B. Knowledge deficit C. Performance deficit D. Transcription error

Correct Answer is C

Explanation

A. Drug preparation error: Drug preparation errors occur when the medication is prepared incorrectly, such as using the wrong diluent, concentration, or technique for reconstitution. In this scenario, the error was not related to how the drug was prepared but rather how it was administered.

B. Knowledge deficit: A knowledge deficit refers to errors stemming from insufficient understanding of medication indications, pharmacology, or administration guidelines. While knowledge may contribute, the primary issue here is a lapse in execution rather than lack of knowledge.

C. Performance deficit: A performance deficit involves an error in the execution of a correct plan, such as administering a medication via the wrong route. Administering a subcutaneous medication intramuscularly reflects a deviation from the correct technique, making this a performance deficit.

D. Transcription error: Transcription errors occur when medication orders are incorrectly recorded or transcribed, leading to wrong doses, routes, or frequencies. In this case, the order itself was likely correct; the mistake occurred during administration, not transcription.

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