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
Explanation
a) Shorter in length: The female urethra is shorter than the male urethra, which makes it easier for bacteria to enter the bladder, increasing the risk of urinary tract infections. This difference is important when performing catheterization.
b) Longer in length: The male urethra is longer than the female urethra.
c) No connection with the bladder: Both the male and female urethras are connected to the bladder.
d) Has different innervation: While there are some differences in the innervation of male and female genital areas, the basic innervation of the urethra is similar for both sexes.
Correct Answer is A
Explanation
a) Compare the total intake and output of fluids for the 24 hours: To assess fluid balance and status, the nurse must compare the intake and output of fluids. This helps to determine whether the patient is retaining or losing fluids.
b) Compare the patient's intake with the normal range of adult fluid intake: While this is useful for understanding general fluid needs, it does not directly assess the patient's fluid status. The comparison should be between intake and output.
c) Ensure the information is included in the verbal end-of-shift report: While this is good practice, the focus should be on using the information to assess the patient's fluid balance.
d) Report the exact milliliter of intake to the physician's office nurse: The exact intake should be recorded in the patient's chart and used for clinical decision-making, but it does not need to be reported to a physician's office nurse unless specified.
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