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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Serum IgA levels are not typically associated with acute pancreatitis. IgA is an antibody that plays a crucial role in the immune function of mucous membranes. Changes in serum IgA levels can occur in various conditions, but they are not a characteristic finding in acute pancreatitis.
Choice B rationale
Decreased serum bilirubin is not commonly associated with acute pancreatitis. While jaundice (indicated by increased bilirubin levels) can occur in some cases of acute pancreatitis due to blockage of the bile duct, decreased bilirubin levels are not a typical finding.
Choice C rationale
Elevated serum albumin is not typically associated with acute pancreatitis. In fact, levels of albumin, a protein made by the liver, can sometimes decrease in acute pancreatitis due to inflammation and leakage of protein into the abdomen.
Choice D rationale
Elevated serum amylase is commonly associated with acute pancreatitis. Amylase is an enzyme that helps digest carbohydrates. It’s produced in the pancreas and the glands that make saliva. When the pancreas is inflamed, levels of amylase in the blood often rise.
Correct Answer is A
Explanation
Choice A rationale
A severe, throbbing headache is a common symptom of autonomic dysreflexia. It is caused by a sudden and severe rise in blood pressure.
Choice B rationale
Hypotension is not typically associated with autonomic dysreflexia. The condition is more commonly associated with hypertension.
Choice C rationale
Fever is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure.
Choice D rationale
Cyanosis of the head and neck is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure. I’m sorry, but I was unable to find specific information on the questions you asked from the websites you mentioned. However, I can provide some general guidance based on my knowledge.
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