A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

Measure the client's gastric residual every 12 hr.

Keep the client's head elevated at 15° during feedings.

Obtain the client's electrolyte levels every 4 hr.

Flush the client's tube with 30 mL of water every 4 hr.

Answer and Explanation

The Correct Answer is D

A) Measure the client's gastric residual every 12 hr: While monitoring gastric residual volume is important to prevent complications such as aspiration or gastric distention, it is typically done prior to each intermittent feeding, not every 12 hours for clients receiving continuous enteral feedings. Continuous feeding does not necessitate less frequent monitoring of gastric residuals.

B) Keep the client's head elevated at 15° during feedings: Elevating the client's head during feedings helps reduce the risk of aspiration. However, this action is not specific to initiating continuous enteral feedings and should be maintained throughout the client's enteral feeding regimen.

C) Obtain the client's electrolyte levels every 4 hr: Monitoring electrolyte levels every 4 hours is not necessary as part of routine care for a client initiating continuous enteral feedings. While electrolyte levels may be monitored periodically, the frequency would depend on the client's clinical condition and the healthcare provider's orders.

D) Flush the client's tube with 30 mL of water every 4 hr: Flushing the client's tube with water helps maintain patency and prevent clogging, which is especially important for clients receiving continuous enteral feedings. This action helps ensure that the tube remains clear and functional, allowing for uninterrupted delivery of the enteral feeding solution.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) "This is a cephalhematoma, which can occur spontaneously":

This is the correct response. A cephalhematoma is a collection of blood between the skull bone and its periosteum and does not cross suture lines. It often develops after vacuum extraction during delivery due to rupture of blood vessels. It is typically benign and resolves on its own over several weeks to months as the blood is reabsorbed by the body. It is important to reassure the mother that this is a common occurrence and usually resolves without intervention.

B) "Mongolian spots can be found on the skin of many newborns":

Mongolian spots are blue-gray birthmarks that commonly appear on the skin of newborns, typically over the buttocks and lower back. They are not related to the swelling on the baby's head and do not cross suture lines.

C) "This is erythema toxicum, which is a transient condition":

Erythema toxicum is a benign rash that appears in many newborns within the first few days of life. It presents as small, yellow or white papules surrounded by erythema and often resolves without treatment within a week. It is not related to the swelling on the baby's head and does not cross suture lines.

D) "A caput succedaneum occurs due to compression of blood vessels and will cross the sutures lines on the baby's head":

While a caput succedaneum is a collection of serosanguinous fluid that crosses suture lines and typically resolves within a few days after birth, it is usually associated with swelling over the presenting part of the fetus during labor, not vacuum extraction. Additionally, caput succedaneum is not typically located on the top of the head, where the swelling from a cephalhematoma would be observed.

A. Hypernatremia B. Weak pulses C. Exaggerated reflexes D. Muscle weakness

Correct Answer is D

Explanation

A) Hypernatremia refers to elevated sodium levels in the blood and is not consistent with water intoxication. In water intoxication, hyponatremia (low sodium levels) is more likely due to dilutional effects from excess water intake.

B) Weak pulses are not specific findings associated with water intoxication. While fluid overload can lead to cardiovascular complications, such as hypertension and bounding pulses, weak pulses are not typically indicative of water intoxication.

C) Exaggerated reflexes are not characteristic findings of water intoxication. Instead, neurological symptoms such as confusion, headache, and seizures may occur due to cerebral edema resulting from water intoxication.

D) Muscle weakness is a potential manifestation of water intoxication due to hyponatremia, which can lead to changes in osmolarity and cellular function. Hyponatremia can cause neurological symptoms such as muscle weakness, lethargy, and seizures. As water moves into cells, it can disrupt cellular function and lead to symptoms of cellular swelling. Therefore, muscle weakness is a concerning finding in the context of suspected water intoxication.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

A nurse in the emergency department is assessing a young adult client who was administered a hypotonic IV fluid bolus for rehydration after collapsing at an athletic event. Which of the following findings indicates the client is experiencing water intoxication?

Correct Answer is D

Explanation

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

A nurse is teaching a group of nurses about the dietary practices to consider when planning care for clients who follow a kosher diet. Which of the following dietary practices should the nurse include in the teaching?

A nurse is caring for a client who is malnourished. The client states, "When I do eat, I usually just eat bread and butter to get someth“ng in me." The nurse should recognize that the client is a risk for which ”f following complications?

A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

A nurse is caring for a client who has myasthenia gravis. Which of the following actions should the nurse take?

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?

A school nurse is providing dietary teaching to a group of adolescent students. Which of the following information should the nurse include?

A nurse is caring for a client who has acute kidney injury and has been prescribed total parenteral nutrition (TPN). When educating the client on the use of TPN, which of the following information should the nurse include?