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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Removing tight clothing is correct because it allows for better heat dissipation and helps cool the patient.
B. Administering acetaminophen is incorrect as acetaminophen reduces fever from infection, not from heat stroke, which requires active cooling measures.
C. Giving salt tablets is incorrect as rapid sodium replacement can cause dangerous fluid shifts; IV fluids are preferred for controlled electrolyte correction.
D. Placing in cool water is correct because immersion cooling is one of the most effective methods to lower body temperature in heat stroke.
E. Initiating IV fluids is correct as the patient likely has dehydration and electrolyte imbalances, requiring fluid resuscitation with isotonic fluids.
Correct Answer is ["A","B","C","E"]
Explanation
A. Ability to meet life's challenges is correct because psychosocial and spiritual interventions provide coping mechanisms and resilience.
B. Hope is correct as these interventions help instill optimism and a sense of purpose.
C. Will to survive is correct since emotional and spiritual support can enhance motivation and perseverance.
D. Fear is incorrect because these interventions are intended to reduce fear rather than cause it.
E. Energy is correct because improving mental well-being can contribute to increased vitality and motivation.
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