The nurse suspects that a patient who underwent esophageal surgery has a misplaced jejunostomy feeding tube. Which action would the nurse take?
Reinsert the tube
Reposition the tube
Document the findings and administer prescribed feedings
Notify the healthcare provider immediately
The Correct Answer is D
Choice A reason: Reinserting the tube without confirming its correct placement can cause harm or lead to complications. It is not the nurse's role to reinsert the tube without proper verification.
Choice B reason: Repositioning the tube without verifying its placement could also cause harm. Ensuring correct placement should be done before any attempts to reposition the tube.
Choice C reason: Documenting the findings and administering feedings without confirming the tube's correct placement can result in serious complications, such as feeding into the wrong location.
Choice D reason: Notifying the healthcare provider immediately is the appropriate action. The provider can order verification of tube placement, such as through an X-ray, to ensure it is correctly positioned before any feedings are administered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Dehydration can cause muscle cramping, but it is not the most specific indicator of acute pancreatitis. The focus in this condition is more on electrolyte imbalances and systemic effects.
Choice B reason: Hypermagnesemia, or elevated magnesium levels, can lead to muscle weakness rather than cramping. It is not a common symptom of acute pancreatitis.
Choice C reason: Hypocalcemia, or low calcium levels, is a typical sign of acute pancreatitis and can cause muscle cramping and spasms. The inflammation of the pancreas can lead to the sequestration of calcium in fatty areas, resulting in low serum calcium levels.
Choice D reason: Hyperkalemia, or elevated potassium levels, can cause muscle weakness and cardiac issues but is not specifically associated with muscle cramping in acute pancreatitis.
Correct Answer is C
Explanation
Choice A reason: A bladder infection can cause various symptoms, but blood-tinged urine is less specific to it.
Choice B reason: Dehydration typically leads to concentrated urine, not blood-tinged urine.
Choice C reason: Prostate enlargement (benign prostatic hyperplasia) can cause blood-tinged urine due to irritation and pressure on the urethra.
Choice D reason: Pernicious anemia affects red blood cell production but is not directly related to the presence of blood in the urine.
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