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 A

Explanation

A. A stand assist lift: A stand assist lift is appropriate for clients who can bear some weight and have upper body strength. It provides support during the transfer while allowing the client to participate in the movement, promoting mobility and independence.

B. A footboard: A footboard is used to prevent foot drop in bedridden clients and is not a transfer device. It does not assist with movement from a chair to a bed.

C. A slide board: A slide board is typically used for clients who have good upper body strength but cannot bear weight on their legs, such as paraplegic clients. Since this client can bear partial weight, a slide board is not the best option.

D. A mechanical lift with a full-body sling: A full-body sling mechanical lift is used for clients who cannot bear weight and have minimal or no upper body strength. Since this client can bear some weight and has upper body strength, a stand assist lift is the more appropriate choice.

A. Turn on the bed alarm. B. Maintain the bed in the lowest position. C. Place the client in a vest restraint. D. Administer a sedative. E. Encourage the family to stay with the client.

Correct Answer is ["A","B","E"]

Explanation

A. Turn on the bed alarm. A bed alarm alerts staff when the client attempts to get up, helping prevent falls.

B. Maintain the bed in the lowest position. Keeping the bed low reduces the risk of injury in case the client attempts to get up unassisted.

C. Place the client in a vest restraint. Restraints should be used only as a last resort after less restrictive measures fail. They can cause distress and increase agitation in clients with dementia.

D. Administer a sedative. Sedatives can increase confusion, risk of falls, and respiratory depression, making them an inappropriate first-line intervention.

E. Encourage the family to stay with the client. Having familiar caregivers present can provide reassurance and reduce agitation, making it a beneficial intervention.

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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

A nurse is preparing to transfer a client from a chair to the client's bed. The client can bear partial weight and has upper body strength. Which of the following devices should the nurse use to transfer the client?

Correct Answer is A

Explanation

A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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