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 ["A","B","C","D","F"]
Explanation
a) Daily Weights: Daily weights are an important measure for assessing fluid status, as they can indicate fluid retention or loss.
b) Moisture of oral cavity: The moisture of the oral cavity can be an indicator of dehydration, which affects fluid balance.
c) Intake and Output: Monitoring intake and output is essential for assessing the balance of fluids and electrolytes.
d) Edema: Edema, or fluid retention, is a key sign of altered fluid and electrolyte status.
e) Listen: While listening to lung sounds or heart sounds may provide indirect information about fluid balance, the word "listen" alone is too vague and not a specific parameter for fluid and electrolyte assessment.
f) Skin turgor: Skin turgor is a sign of hydration status. Decreased turgor may indicate dehydration.
Correct Answer is D
Explanation
a) "Have you been having diarrhea?" This is a risk factor or cause of hypokalemia but not a symptom of it. Good to ask, but not the most direct sign.
b) "Have you been experiencing difficulty breathing?" Severe hypokalemia can lead to respiratory muscle weakness, but it is not a common early symptom.
c) "Have you been experiencing chest pain?" Chest pain is not a common symptom of hypokalemia. It could signal cardiac issues, but not specific to low potassium.
d) "Have you been experiencing muscle weakness or leg cramps?" Classic symptoms of hypokalemia due to potassium’s role in muscle contraction and nerve conduction.
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