A tracheostomy patient is experiencing regurgitation of tube feeding formula. What should be the nurse's first priority?
Placing the patient in prone position to improve draining from mouth
Checking to make sure the tracheostomy cuff is inflated during tube feedings
Placing the patient in the right lateral decubitus position to promote gastric emptying
Discussing the use of metoclopramide to facilitate gastric motility with the practitioner
The Correct Answer is B
A. The prone position is not recommended for managing tube feeding regurgitation, as it could lead to aspiration into the lungs.
B. The first priority is to ensure that the tracheostomy cuff is inflated during tube feedings to prevent aspiration and to ensure that the feeding is directed into the stomach and not into the airway.
C. The lateral decubitus position can help with gastric emptying, but the priority is to ensure proper cuff inflation to prevent aspiration.
D. While metoclopramide may help with gastric motility, the immediate concern is managing the risk of aspiration, which requires confirming cuff inflation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Low levels of both HDL and LDL cholesterol is not desirable as low levels of HDL cholesterol are associated with a higher risk for heart disease.
B. Low levels of high-density lipoprotein (HDL cholesterol) are undesirable because HDL helps remove excess cholesterol from the bloodstream, and lower levels increase the risk of cardiovascular disease.
C. Low levels of low-density lipoprotein (LDL cholesterol) is the most desirable situation. Lower LDL levels reduce the risk of atherosclerosis and heart disease, making it important to lower these levels in patients with coronary artery disease.
D. Hypocholesterolemia (abnormally low cholesterol levels) is not typically targeted as a treatment goal and can be harmful in some situations, as cholesterol is essential for many bodily functions.
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.
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