A patient is receiving total parenteral nutrition and has been NPO postoperatively. The physician ordered small amounts of clear liquids today. The nurse's priority is to ensure which criterion is addressed before giving the patient anything by mouth?
Select one:
The patient's current weight.
The presence of the swallow reflex.
The patient has an appetite.
Adequate pulse and blood pressure readings.
The Correct Answer is B
A. While weight is important for overall nutritional monitoring, it is not directly related to the safety of resuming oral intake.
B. Before initiating any oral intake, especially in a patient who has been NPO, it is critical to assess for a functioning swallow reflex to prevent aspiration.
C. Appetite does not ensure that the patient can safely swallow or tolerate oral intake.
D. Vital signs are important but do not determine swallowing safety or aspiration risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I have no appetite." – Loss of appetite (anorexia) is a common and expected symptom of appendicitis.
B. "The pain hurts so much it is making me nauseous." – Incorrect. Severe pain accompanied by nausea is typical in appendicitis and does not require immediate intervention beyond routine care.
C. "If I position myself on my right side, it makes the pain less intense." – Incorrect. Patients often find comfort in certain positions; this statement reflects a common coping mechanism.
D. "The pain seems to be gone now." – Correct. Sudden relief of pain in a patient with appendicitis may indicate rupture of the appendix, which is a medical emergency requiring immediate intervention due to the risk of peritonitis and sepsis.
Correct Answer is D
Explanation
A. Verifying diabetes type is important for long-term management but not the immediate priority in a critical situation.
B. Assessing vital signs is part of the nursing assessment but should come after alerting the care team in a severe hyperglycemic crisis.
C. Administering sliding scale insulin without further evaluation or orders could be dangerous at such a critically high glucose level.
D. A glucose level of 750 mg/dL is dangerously high and may indicate a life-threatening condition such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). The priority action is to immediately notify the RN and provider for urgent intervention and further orders.
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