Which practice guideline should the nurse implement when caring for the patient receiving enteral feedings?
gastric residual volumes of 500 ml should be of concern
gastric residual volume is checked every 2 hours
gastric residual volumes of 100 ml should be of concern.
gastric residual volume is checked every 6 hours
The Correct Answer is A
A. Gastric residual volumes of 500 mL should be of concern: Residual volumes ≥500 mL are associated with increased risk of aspiration and feeding intolerance. At this threshold, the nurse should reassess feeding tolerance and notify the provider.
B. Gastric residual volume is checked every 2 hours: Routine checking every 2 hours is not recommended and may unnecessarily interrupt nutrition. Many guidelines discourage frequent checks unless the patient shows signs of intolerance.
C. Gastric residual volumes of 100 mL should be of concern: A residual of 100 mL is generally considered acceptable and not an indication to stop or hold enteral feedings. Using this low threshold can lead to underfeeding.
D. Gastric residual volume is checked every 6 hours: Scheduled routine checks at fixed intervals are no longer universally recommended. Assessment should be guided by patient condition and clinical signs rather than strict timing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Auscultate for a bruit every 8 hours: Listening for a bruit over the fistula helps detect blood flow and patency. Changes in the quality or absence of a bruit can indicate complications such as thrombosis.
B. Use the fistula for blood draws: Using the fistula for venipuncture or IV access can damage the vascular access and increase the risk of infection or thrombosis. Alternative sites should be used for blood draws.
C. Palpate for a bruit every 4 hours: Feeling for a thrill (vibratory sensation) provides direct assessment of blood flow through the fistula. Regular palpation helps ensure early detection of compromised circulation or clot formation.
D. Palpate for the presence of a thrill every 8 hours: A palpable thrill confirms functional blood flow within the fistula. Routine assessment allows timely recognition of occlusion or other complications.
E. Obtain blood pressure in the extremity that has fistula: Blood pressure should not be taken in the arm with the fistula, as cuff pressure can damage the access and reduce blood flow. This practice is contraindicated to protect vascular integrity.
Correct Answer is A
Explanation
A. Determine the time of symptom onset: Establishing the exact time symptoms began is critical for stroke management, particularly to determine eligibility for thrombolytic therapy. Rapid intervention depends on accurate timing to maximize benefits and minimize risks.
B. Assess for the presence of headache: While headache may provide additional clinical information, it does not take priority over determining symptom onset, which directly guides treatment decisions in acute stroke.
C. Determine the patient's drug allergies: Identifying allergies is important before administering medications, but initial priority focuses on interventions that directly affect neurological outcomes and eligibility for acute therapies.
D. Assess the patient's orientation: Orientation assessment helps gauge neurological status but is secondary to establishing the timeline for intervention. Immediate treatment decisions are guided by onset and type of neurological deficits.
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