A nurse is monitoring a client who has been receiving intermittent enteral feedings which of the following findings should the nurse identify as an indication of intolerance to the feeding?

Nausea

Urine output 40 m/hr

Soft stools

Headache

Answer and Explanation

The Correct Answer is A

A. Nausea: Nausea is a sign of intolerance to enteral feedings and may indicate delayed gastric emptying or feeding that is too rapid. The nurse should slow the rate of feeding, assess for abdominal distention, and check for residual volume.

B. Urine output 40 mL/hr: Urine output of 40 mL/hr is within the normal range (≥30 mL/hr) and does not indicate intolerance to enteral feedings. However, a significant decrease in urine output (oliguria) could indicate dehydration or kidney issues.

C. Soft stools: Soft stools can be a normal response to enteral feedings unless the client develops diarrhea. Watery, frequent stools may indicate malabsorption, but soft stools alone are not a sign of feeding intolerance.

D. Headache: Headaches are not a common symptom of enteral feeding intolerance. They may be related to other issues such as dehydration, hypertension, or medication side effects.

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Correct Answer is D

Explanation

A. Bradypnea: Bradypnea (slow breathing) is not a typical late sign of hypoxia. Instead, clients with worsening hypoxia often develop tachypnea (rapid breathing) as the body tries to compensate for low oxygen levels.

B. Restlessness: Restlessness is an early sign of hypoxia, not a late one. It occurs due to inadequate oxygenation of the brain, leading to agitation and confusion.

C. Hypertension: Hypertension can be an early response to hypoxia as the body attempts to increase oxygen delivery. However, as hypoxia progresses, blood pressure may drop due to worsening oxygen deprivation.

D. Tachycardia: Tachycardia (increased heart rate) is a late sign of hypoxia. The heart compensates for low oxygen levels by increasing cardiac output. However, if untreated, hypoxia can progress to bradycardia and cardiac arrest.

A. Remove a piece of the new dressing that falls 5 cm (2 in) from the edge of the sterile field during the dressing change. B. Begin the dressing change by applying sterile gloves and removing the existing dressing. C. Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray. D. Place the existing dressing on the outermost portion of the sterile field and discard it when the dressing change is finished.

Correct Answer is C

Explanation

A. Remove a piece of the new dressing that falls 5 cm (2 in) from the edge of the sterile field during the dressing change. Incorrect, as the item is contaminated and should not be used.

B. Begin the dressing change by applying sterile gloves and removing the existing dressing. The old dressing should be removed with clean gloves before donning sterile gloves.

C. Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray. Any contamination of the sterile field requires a complete restart to maintain sterility.

D. Place the existing dressing on the outermost portion of the sterile field and discard it when the dressing change is finished. Contaminates the sterile field; old dressings should be disposed of immediately.

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A nurse is monitoring a client who has been receiving intermittent enteral feedings which of the following findings should the nurse identify as an indication of intolerance to the feeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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