A patient is mechanically ventilated and is receiving enteral nutrition via a nasogastric tube. To help ensure feeding tolerance, the nurse checks residual volumes every 4 hours. During a residual check later in the shift, the nurse aspirates a total residual volume of 200 mL. What action should the nurse take next?

Discontinue tube feeding and call the practitioner for parenteral nutrition orders

Stop the tube feeding, wait 1 hour, and recheck the residual

Continue the tube feeding and place the patient in the left lateral decubitus position to facilitate gastric emptying

Continue the tube feeding if no other gastrointestinal symptoms exist and reassess the patient with the next residual check

Answer and Explanation

The Correct Answer is B

A. Discontinuing the tube feeding and transitioning to parenteral nutrition is not the first action, as the residual volume may be manageable with additional interventions.
B. A residual volume of 200 mL is above the usual threshold, so the nurse should stop the feeding, wait, and recheck the residual to assess if it improves.
C. While positioning can help gastric emptying, the immediate action should be to stop the feeding and reassess before continuing.
D. Continuing the feeding without rechecking the residual volume would be premature, as the volume is higher than expected, potentially increasing the risk of aspiration.

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 B

Explanation

A. Helping a client fill out an informed consent form is an example of respect for autonomy but not altruism.
B. Promoting universal access to healthcare aligns with altruism, as it demonstrates selfless concern for the well-being of underserved populations, advocating for the needs of others.
C. Consulting a client about priorities is important in person-centered care but reflects respect for autonomy and shared decision-making, not altruism specifically.
D. Researching the culture of a Muslim client shows cultural sensitivity but does not directly demonstrate altruism.

A. Encourage the patient to deny the presence of the illness B. Encourage the patient to let the staff have total control of the patient's care. C. Foster trust in the interprofessional health care team. D. Inform the patient that everything will be all right

Correct Answer is C

Explanation

A. Encouraging denial of illness is incorrect as denial is not a healthy coping mechanism and may hinder treatment adherence.
B. Encouraging the patient to let staff have total control is incorrect because patient autonomy and involvement in care decisions enhance coping and emotional well-being.
C. Fostering trust in the interprofessional health care team is correct as it helps the patient feel supported and engaged in their care, reducing anxiety and promoting better coping strategies.
D. Telling the patient that everything will be all right is incorrect because it is a false reassurance that does not validate the patient's feelings or situation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse demonstrates the professional value known as altruism when caring for clients in a long-term care facility. What nursing action demonstrates this behavior?

Correct Answer is B

Explanation

Which therapeutic technique may be used to enhance coping in the critical care environment?

Correct Answer is C

Explanation

The nurse is exploring pain assessment with a group of new nurses. Which statements are true regarding pain assessment and management? (Select all that apply, one, some, or all.)

An adult client with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show?

A patient is brought to the ED by a friend who states that a tree fell on the patient’s leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)

Provider Orders normal saline (NS) 0.9% 650 ml infuse over 6 hours. The drip factor is 10 gtt/mL. How many drops per minute (gtts/min) will be administered? NOTE DO NOT write the unit/s of measurement YOUR ANSWER SHOULD BE IN WHOLE NUMBER

Which combinations of drugs have been found to be effective in managing the pain associated with musculoskeletal and soft tissue inflammation?

A client is complaining of severe chest pain became unresponsive and the cardiac monitor shows the heart rhythm below. What will be the most appropriate actiondropdown. What is the heart rhythmdropdown

A patient is admitted with severe malnutrition. A central venous catheter is placed in the right subclavian vein and total parenteral nutrition (TPN) is started. What medical interventions may be initiated with the onset of hyperglycemia?

The nurse is caring for a patient with liver dysfunction. What is the maximum dose of acetaminophen the patient should receive in 24 hours?