The nurse is assessing tube feeding residual amounts and finds 10ml of residual.

The client is receiving 60ml/hr of feeding.

What action should the nurse take?

Increase the feeding to 35ml/hr.

Decrease the feeding to 10ml/hr.

Continue the feeding as ordered.

Hold the feeding and notify the doctor.

Answer and Explanation

The Correct Answer is C

A gastric residual volume of 10ml is not considered high. The client is receiving 60ml/hr of feeding, which is within normal limits. Therefore, the nurse should continue the feeding as ordered.

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Correct Answer is C

Explanation

Choice A rationale
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
Choice B rationale
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
Choice C rationale
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
Choice D rationale
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.

A. A patient with type 1 diabetes who has taken a high dose of insulin. B. A patient with type 2 diabetes who has not taken any medication. C. An elderly patient who is taking an antibiotic for an infection. D. A patient with metabolic syndrome who is taking a statin to lower cholesterol levels.

Correct Answer is A

Explanation

Choice A rationale
A patient with type 1 diabetes who has taken a high dose of insulin is at the highest risk for developing hypoglycemia. Insulin lowers blood glucose levels, and taking a high dose can cause the levels to drop too low.
Choice B rationale
A patient with type 2 diabetes who has not taken any medication is not at a high risk for developing hypoglycemia. Without medication, their blood glucose levels may be high, not low.
Choice C rationale
An elderly patient who is taking an antibiotic for an infection is not at a high risk for developing hypoglycemia. Antibiotics do not typically affect blood glucose levels.
Choice D rationale
A patient with metabolic syndrome who is taking a statin to lower cholesterol levels is not at a high risk for developing hypoglycemia. Statins do not typically affect blood glucose levels.

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The nurse is assessing tube feeding residual amounts and finds 10ml of residual. The client is receiving 60ml/hr of feeding. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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The nurse is assessing tube feeding residual amounts and finds 10ml of residual.

The client is receiving 60ml/hr of feeding.

What action should the nurse take?