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 A
Explanation
A. Respiratory acidosis is correct because the patient has a low pH (acidosis) and elevated PaCO₂, indicating hypoventilation as the primary cause.
B. Metabolic alkalosis is incorrect because bicarbonate is within the normal range, and there is no metabolic compensation.
C. Respiratory alkalosis is incorrect because alkalosis would present with a high pH and low PaCO₂, the opposite of this scenario.
D. Metabolic acidosis is incorrect because bicarbonate is normal, ruling out a metabolic cause.
Correct Answer is ["G"]
Explanation
A. History of type 2 diabetes is not a rhythm characteristic seen on an ECG. While diabetes can contribute to the development of cardiovascular issues, it does not specifically describe the characteristics of a third-degree AV block on an ECG.
B. Interval and RR interval are irregular is incorrect. In third-degree AV block (also known as complete heart block), the atrial rate and ventricular rate are typically regular, but the atrial and ventricular rhythms are completely dissociated.
C. Shortened PR interval is incorrect. In third-degree AV block, there is no consistent PR interval because the atria and ventricles are functioning independently.
D. Inconsistently shaped P waves is incorrect. P waves may appear normal, but the relationship between P waves and QRS complexes is lost in third-degree AV block.
E. PR interval is constant is incorrect. In third-degree AV block, the PR interval is inconsistent or absent, as the atrial and ventricular rates are independent of each other.
F. Apical heart rate is irrelevant here. The ECG will show the characteristic findings of third-degree AV block rather than focusing on apical heart rate alone.
G. Fewer QRS complexes than P waves is correct. In third-degree AV block, the atrial impulses (P waves) are conducted normally, but the ventricles are completely dissociated from the atrial rhythm, leading to fewer QRS complexes than P waves, as the ventricles may be paced by an escape rhythm.
H. PP interval is equal to RR interval is not necessarily true in third-degree AV block. The PP and RR intervals may be different depending on the escape rhythm, but they are not usually exactly equal.
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