A staff nurse is supervising a newly licensed nurse who is preparing to administer an intermittent tube feeding to a client. Which of the following actions by the newly licensed nurse is appropriate?
Checking residual volume before each feeding
Flushing the tube with 15 mL of water
Elevating the head of the bed to a 20" angle
Adding colored food dye to the formula
The Correct Answer is A
Rationale:
A. Checking residual volume prior to each feeding is appropriate to assess tolerance and reduce the risk of aspiration.
B. Flushing the tube should be done with at least 30 mL of water (not 15 mL) to maintain patency and prevent clogging.
C. The head of the bed should be elevated to at least 30° to 45°, not 20°, to reduce aspiration risk.
D. Adding food dye to formula is contraindicated due to the risk of adverse effects and is not evidence-based practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. A client whose TPN was discontinued and is requesting clear liquids can safely progress diet as prescribed but does not represent an immediate threat to life.
B. Delayed capillary refill after a cardiac catheterization indicates decreased perfusion, possibly from an arterial occlusion or compromised circulation at the insertion site. This is a priority because impaired circulation can lead to limb ischemia and loss if not addressed immediately.
C. Pain management for a postoperative client is important but not life-threatening and can be addressed after circulation is ensured.
D. An oxygen saturation of 90% in a client with COPD may be acceptable, as their baseline oxygen saturation is often lower than average, making this a lesser priority compared to impaired perfusion.
Correct Answer is D
Explanation
Rationale:
A. Dysarthria (difficulty with articulation) is a speech problem that requires referral to a speech-language pathologist, not an occupational therapist.
B. Difficulty swallowing indicates dysphagia, which also requires referral to a speech-language pathologist, not an occupational therapist.
C. Managing new medications requires teaching and monitoring by the nurse or pharmacist, not an occupational therapist.
D. An occupational therapist (OT) helps clients regain independence in activities of daily living (ADLs) such as cooking, dressing, and grooming. Since the client enjoys meal preparation, the OT can provide strategies and adaptive equipment to help safely resume this meaningful activity.
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