A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding. (Move the steps, placing them in the selected order of performance. All steps must be used.)
Verify tube placement
Check the residual feeding contents
Evaluate tolerance of feeding
Administer the feeding
The Correct Answer is A,B,D,C
A. Verify tube placement: This is the first step to ensure that the tube is in the correct position and not in the lungs, which could lead to aspiration.
B. Check the residual feeding contents: This helps to assess gastric emptying and ensure that the stomach can tolerate the feeding. If there is a large amount of residual, the feeding may be delayed or the rate may need to be adjusted.
D. Administer the feeding: Once tube placement is confirmed and residual contents are assessed, the feeding can be administered at the prescribed rate.
C. Evaluate tolerance of feeding: After the feeding is complete, it's important to monitor the client for signs of tolerance, such as the absence of nausea, vomiting, or abdominal distension.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This refers to irregular bleeding between menstrual periods. While anorexia nervosa can lead to amenorrhea (the absence of menstruation) due to hormonal imbalances from severe weight loss and malnutrition, metrorrhagia is not a typical finding associated with anorexia nervosa.
B. This is a condition characterized by elevated levels of potassium in the blood. It is not a common finding in anorexia nervosa. Instead, clients with anorexia nervosa are more likely to have electrolyte imbalances such as hypokalemia (low potassium levels), especially if they engage in behaviors like vomiting or excessive use of laxatives.
C. This is a common finding in clients with anorexia nervosa. Constipation occurs due to inadequate intake of food and fluids, which results in decreased bowel motility. Malnutrition and dehydration from restricted intake can also contribute to this problem.
D. This refers to an abnormally fast heart rate. While tachycardia can occur in various conditions, in the context of anorexia nervosa, clients may actually exhibit bradycardia (slow heart rate) rather than tachycardia. The low body weight and malnutrition associated with anorexia can lead to a slowed heart rate as part of the body's response to starvation and decreased metabolic activity.
Correct Answer is B
Explanation
A. Decreasing gastric acid secretions is not the primary mechanism of action for metoclopramide. This action is more characteristic of medications like proton pump inhibitors (PPIs) or H2 receptor antagonists, which reduce stomach acid to help with conditions such as GERD or peptic ulcers.
B. Promoting gastric emptying is the correct explanation for how metoclopramide relieves nausea. Metoclopramide acts as a prokinetic agent, meaning it enhances gastrointestinal motility by increasing the movement of the stomach and intestines.
C. Slowing peristalsis is not the mechanism of action for metoclopramide. In fact, metoclopramide does the opposite by increasing peristalsis and gastrointestinal motility. Slowing peristalsis would typically exacerbate nausea and lead to delayed gastric emptying, which metoclopramide aims to counteract.
D. Relaxing gastric muscles is not how metoclopramide works. Metoclopramide’s primary action is to increase gastrointestinal motility rather than relaxing the gastric muscles. Other medications, such as antispasmodics, might be used to relax gastrointestinal muscles, but metoclopramide is not used for this purpose.
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