The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? (SELECT ALL THAT APPLY)

Solution provided

Name of physician prescribing the feeding

Client tolerance of the feeding

Amount of solution

Duration of the feeding

Answer and Explanation

Correct Answer : A,C,D,E

A. Documenting the type of solution provided for tube feeding is essential for accurate record-keeping and continuity of care. This includes specifying the name and composition of the enteral formula used, such as standard polymeric, high-protein, elemental, or specialized formulas for specific medical conditions or nutritional needs.
C. Documenting the client's tolerance of the tube feeding is crucial for monitoring their response to the enteral nutrition. This includes assessing for signs of intolerance, such as nausea, vomiting, abdominal pain, bloating, diarrhea, or aspiration. Documenting tolerance helps guide adjustments to the feeding regimen and ensures patient safety and comfort.
D. Documenting the amount of solution administered during the tube feeding is essential for accurately monitoring the client's intake and ensuring that nutritional goals are met. This includes recording the volume of formula administered, as well as any additional flushes or medications given through the feeding tube.
E. Documenting the duration of the tube feeding session provides important information about the timing and frequency of feedings. This includes recording the start and end times of the feeding, as well as any interruptions or adjustments made during the procedure. Documenting the duration helps ensure consistency in the feeding regimen and facilitates effective communication among healthcare providers.
B. Documenting the name of the physician who prescribed the tube is not necessary.

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Correct Answer is C

Explanation

C. Respect for the deceased person's cultural and religious beliefs is crucial. Care should be provided in a manner that aligns with their customs and traditions. This may involve specific rituals, prayers, or practices depending on the individual's cultural or religious background.
A. While completing documentation on the death certificate is important for legal and administrative purposes, it is not the priority during post-mortem care.
B. While it's essential to handle the deceased person's belongings with care and ensure they are returned to the family, this task can typically wait until after the immediate post-mortem care has been provided. It's not the priority during the initial stages of post-mortem care.
D. This task is important, but it should be carried out after the completion of post-mortem care. Once the deceased person has been respectfully prepared, the next step is to transfer them to the morgue or the designated location.

A. decreased blood glucose B. Increased mental acuity C. Increased urine retention D. increased bronchial dilation E. decreased pupil size

Correct Answer is ["B","C","D"]

Explanation

B. Increased mental acuity, or heightened alertness and cognitive function, is a characteristic response during the alarm stage of GAS. The body's stress response enhances mental focus and perception to help the individual recognize and respond to the stressor effectively.
C. During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the release of adrenaline (epinephrine) and norepinephrine. These hormones stimulate the kidneys to conserve water and sodium, leading to decreased urine output and increased urine retention. Therefore, increased urine retention is an expected physiologic manifestation in the alarm stage.
D. During the alarm stage, the sympathetic nervous system activation leads to bronchodilation, allowing for increased airflow to the lungs. This facilitates improved oxygenation of the blood and enhances the individual's ability to respond to the stressor by increasing oxygen delivery to tissues.
A. During the alarm stage of GAS, the body initiates the fight-or-flight response, which leads to the release of stress hormones such as cortisol and adrenaline. These hormones increase blood glucose levels through processes like glycogenolysis and gluconeogenesis to provide energy for the body to respond to the stressor. Therefore, decreased blood glucose is not an expected manifestation in the alarm stage.
E. Decreased pupil size: During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the dilation of pupils (mydriasis). This allows for improved visual acuity and peripheral vision, enhancing the individual's ability to detect potential threats or stimuli in the environment.

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The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

The nurse is performing post-mortem care on a client who has just died. What nursing care should be given priority?

Correct Answer is C

Explanation

Which of the following are physiologic manifestations which occur in the alarm stage of the General Adaptation Syndrome? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

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