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

Answer and Explanation

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.

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Correct Answer is A

Explanation

a) Fluid retention: A weight increase of 6 pounds in 1 day is significant and may indicate fluid retention, which is commonly seen in conditions like heart failure or kidney disease.

b) Increased nutritional intake: A 6-pound weight gain is unlikely to be due to nutritional intake alone, especially over just a two-day period. This would more likely be seen over a longer timeframe.

c) Anorexia: Anorexia is associated with weight loss, not weight gain.

d) Weight loss: The patient has gained weight, not lost it.

A. shorter in length B. longer in length C. no connection with bladder D. has different innervation

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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