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A patient had abdominal surgery for gastrostomy tube placement and has enteral feedings in fusing at 75ml/hr. She is stating that she is" nauseated and has vomited twice". After completing your assessment, you note that her abdomen is distended, and she has had 5-7 loose and runny stools over the last 24 hours. What is the next action for the nurse to take?

A.

Discontinue the feedings and notify the physician of your assessment findings

B.

Continue feedings as ordered

C.

Administer prn pain medication

D.

This is a normal response, continue feedings as ordered

Answer and Explanation

The Correct Answer is A

a) Discontinue the feedings and notify the physician of your assessment findings: These are signs of feeding intolerance or possible complications such as delayed gastric emptying, infection, or dumping syndrome. Stopping the feeding prevents further distress, and the physician should be informed promptly.

b) Continue feedings as ordered: Continuing feedings may worsen the symptoms and put the patient at risk for aspiration or further gastrointestinal complications.

c) Administer prn pain medication: Pain medication will not address the underlying issue of nausea, vomiting, and GI symptoms. It may also mask symptoms or cause further GI upset.

d) This is a normal response, continue feedings as ordered: These symptoms are not normal. Nausea, vomiting, distention, and frequent diarrhea suggest a problem with the feeding regimen.


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Related Questions

Correct Answer is A

Explanation

a) Providing a skin barrier for any drainage at the site: Protecting the skin from moisture or drainage prevents further irritation or breakdown. Skin barriers help maintain skin integrity.

b) Turn the client to the side: Positioning may help with aspiration prevention but does not address skin irritation around the G-tube site.

c) Apply adhesive bandage directly to the skin: Adhesive bandages can further irritate or damage already sensitive skin and are not recommended for irritated or moist areas.

d) Keep the head of bed 25 degrees: While semi-Fowler’s positioning (30–45°) is good for preventing aspiration, this is unrelated to treating skin irritation directly.

Correct Answer is B

Explanation

a) Hemoglobin (Hgb) 11.3 g/dL: While a hemoglobin level of 11.3 g/dL is slightly below normal, it is not a definitive indicator of malnutrition. It may be related to anemia but not necessarily malnutrition.

b) Pre-albumin 10 mg/dL: Pre-albumin is a protein that reflects short-term nutritional status. A value of 10 mg/dL is below the normal range and suggests malnutrition, as pre-albumin levels decrease in states of inadequate protein intake.

c) Creatinine 1.9 mg/dL: Elevated creatinine levels typically indicate kidney dysfunction, not malnutrition. It is a marker of kidney health, not nutritional status.

d) Hematocrit (Hct) 56%: A hematocrit level of 56% is elevated, which could indicate dehydration, polycythemia, or other conditions, but it is not a direct indicator of malnutrition.

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