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","B","D","E"]
Explanation
A. Equianalgesic dosing compares other opioids to morphine to ensure that equivalent pain relief is achieved.
B. For patients unable to verbalize pain, behavioral indicators such as facial expressions or body movements are the best way to assess pain.
C. Meperidine is not stronger than morphine and has a higher risk of toxicity, especially when given at higher doses or frequent intervals.
D. The patient’s self-report is considered the most accurate and essential tool for assessing pain.
E. Transcutaneous electrical nerve stimulation and heat/cold therapy work by stimulating nonpain sensory fibers, which can help alleviate pain by overriding pain signals.
Correct Answer is D
Explanation
A. Elevated ST segment is typically seen with conditions like pericarditis or acute myocardial injury, not hypokalemia.
B. Wide QRS could be related to various conditions, including bundle branch block or electrolyte disturbances, but it is not specifically indicative of hypokalemia.
C. Inverted P wave could be due to atrial arrhythmias but is not a hallmark of hypokalemia.
D. Abnormally prominent U wave is a classic sign of hypokalemia and is often seen following the T wave on an EKG.
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