A nurse is caring for a patient who is receiving enteral feeding. Which of the following interventions is the highest priority when the nurse suspects aspiration of the feeding?
Auscultate breath sounds
Stop the feedings
Obtain a chest x-ray
Initiate antibiotic therapy
The Correct Answer is B
a) Auscultate breath sounds: While auscultating breath sounds may reveal signs of aspiration (e.g., crackles), stopping the feedings is the immediate priority to prevent further aspiration and reduce the risk of complications like aspiration pneumonia.
b) Stop the feedings: The highest priority is to stop the enteral feedings immediately to prevent further aspiration and potential damage to the lungs, followed by further assessments.
c) Obtain a chest x-ray: A chest x-ray can confirm the presence of aspiration or pneumonia but is not the immediate priority. Stopping the feedings is more urgent.
d) Initiate antibiotic therapy: Antibiotics may be needed if aspiration pneumonia is suspected, but they should not be the first intervention. Stopping the feedings and assessing the patient should be done first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a) Have edema to the lower extremities: Edema can be caused by various factors such as heart failure, kidney disease, or poor circulation, but it is not directly related to a balance between energy intake and expenditure.
b) Increase: If energy intake equals energy expenditure, there is no surplus of energy to cause weight gain.
c) Decrease: If energy intake equals energy expenditure, there is no energy deficit to cause weight loss.
d) Stay the same: When a person's daily energy intake equals their total energy expenditure, their weight remains stable because the amount of energy taken in is exactly balanced with the amount of energy used.
Correct Answer is A
Explanation
a) Clear Liquid Diet: A clear liquid diet consists of liquids that are clear at room temperature, such as broth, tea, and clear juices. It requires minimal digestion and leaves minimal residue, making it ideal for clients with gastrointestinal issues, post-surgery, or before certain diagnostic tests.
b) Renal Diet: A renal diet is designed for patients with kidney disease and focuses on limiting protein, sodium, potassium, and phosphorus intake. It is not composed solely of clear liquids.
c) Mechanically Altered Diet: A mechanically altered diet involves foods that are chopped, pureed, or ground to aid in chewing or swallowing, not just clear liquids.
d) Pureed Diet: A pureed diet consists of foods that are blended or mashed into a smooth consistency, not clear liquids that become fluid at body temperature.
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