A nurse is caring for a patient who receives intermittent enteral feedings through an NG tube.
Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
To determine the patient’s electrolyte balance
To confirm the placement of the NG tube
To remove gastric acid that might cause dyspepsia
To identify delayed gastric emptying
The Correct Answer is D
Choice A rationale
While electrolyte balance is important in patient care, it is not the primary reason for measuring gastric residual before administering a feeding through an NG tube.
Choice B rationale
Confirming the placement of the NG tube is crucial before administering a feeding. However, measuring the gastric residual is not the primary method used to confirm tube placement.
Choice C rationale
Removing gastric acid that might cause dyspepsia is not the main purpose of measuring gastric residual. Dyspepsia, or indigestion, is typically managed with medications and dietary modifications.
Choice D rationale
The primary purpose of measuring gastric residual is to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. If gastric emptying is delayed, the nurse should avoid overfeeding the patient and causing gastric distention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiceD.
Choice A rationale:
Introducing a regular diet is not the immediate priority for a child with severe diarrhea.The focus should be on stabilizing the child’s condition before reintroducing regular foods.
Choice B rationale:
Maintaining fluid therapy is important, but it is part of the broader goal of managing fluid balance.It is not the first step in addressing severe diarrhea.
Choice C rationale:
Rehydration is crucial, but it falls under the broader category of assessing and managing fluid balance.Ensuring the child is properly hydrated is part of the overall assessment.
Choice D rationale:
Assessing fluid balance is the priority action. This involves evaluating the child’s hydration status, monitoring for signs of dehydration, and ensuring that fluid therapy is appropriately managed.This step is critical to prevent complications from severe diarrhea.
Correct Answer is A
Explanation
Choice A rationale
An elevated white blood cell (WBC) count in a urinalysis can indicate an infection or inflammation in the body. A count of 10 is higher than the normal range, which is typically 0 to 5 WBCs per high power field.
Choice B rationale
Occasional casts in the urine are not typically a cause for concern. Casts are tiny tube-shaped particles that can form due to kidney conditions, but occasional casts can be normal.
Choice C rationale
A pH of 5.0 is within the normal range for urine pH, which is typically between 4.6 and 8.0.
Therefore, this result would not typically need to be communicated to the provider.
Choice D rationale
Dark amber color of the urine can be a sign of dehydration, but it can also be influenced by certain foods, medications, and health conditions. It is not typically a result that needs to be communicated to the provider.
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