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 A

Explanation

Choice A rationale
Medicate the client 30 minutes before the procedure. This is the correct action. Administering pain medication 30 minutes before the procedure allows the medication to take effect and provides pain control during the procedure.
Choice B rationale
Reassure the client that the procedure is not painful. This is not accurate. Debridement and hydrotherapy can be painful, so it’s important to manage the client’s pain effectively.
Choice C rationale
Utilize meditation and imagery. While these techniques can be helpful adjuncts to pain management, they should not replace pharmacological pain management in this situation.
Choice D rationale
Administer pain medication around the clock. While it’s important to manage pain effectively, this does not specifically address the client’s needs during the hydrotherapy and debridement procedure.

A. Pupils are 3 mm, equal and reactive to light B. Client is sleeping and is difficult to arouse C. Respirations are 10/min D. Pulse oximetry is 87% on room air .

Correct Answer is D

Explanation

Choice A rationale
Pupils being 3 mm, equal and reactive to light is a normal finding and does not require further action.
Choice B rationale
The client being difficult to arouse could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice C rationale
Respirations being 10/min could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice D rationale
Pulse oximetry reading of 87% on room air is concerning. Normal pulse oximetry readings are typically between 95% and 100%. A reading of 87% indicates the client is not getting enough oxygen, which requires immediate action.

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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

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Explanation

Correct Answer is D

Explanation

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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?