Which symptom experienced by a client receiving a continuous enteral feeding via a nasogastric tube requires priority follow-up by the nurse?
The client has frequent coughing spells.
The client reports mild abdominal cramps.
The client has high-pitched bowel sounds.
The client reports one to two soft bowel movements per day.
The Correct Answer is A
This is because coughing can indicate aspiration of the feeding into the lungs, which can lead to pneumonia and other serious complications. Aspiration is reported in up to 89% of patients receiving nasogastric tube feeding.
Therefore, the nurse should prioritize assessing the client for signs of aspiration and ensuring proper tube placement.
Choice B is wrong because mild abdominal cramps are a common side effect of nasogastric tube feeding and do not require immediate intervention unless they are severe or persistent.
Choice C is wrong because high-pitched bowel sounds are normal and indicate peristalsis and digestion.
They do not indicate a problem with the tube feeding.
Choice D is wrong because one to two soft bowel movements per day are desirable and indicate adequate nutrition and hydration.
They do not indicate a problem with the tube feeding.
Normal ranges for gastric residual volume are less than 200 mL for adults and less than 100 mL for children. Normal ranges for pH of gastric aspirate are 1 to 5.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the priority nursing diagnosis for a client who has had vomiting and diarrhea for the past three days because it poses the greatest threat to the client’s health and well-
being. Fluid loss can lead to hypovolemia, hypotension, shock, electrolyte imbalance, and renal failure.
Choice A is wrong because fatigue is a subjective symptom that may or may not be related to fluid loss.
It is not a priority over fluid volume deficit.
Choice C is wrong because impaired skin integrity is a potential problem that may occur due to irritation from vomiting and diarrhea, but it is not a priority over fluid volume deficit.
Choice D is wrong because imbalanced nutrition is a potential problem that may occur due to vomiting, but it is not a priority over fluid volume deficit.
Correct Answer is B
Explanation
This is because the nurse’s reply does not address the client’s fear of radiation therapy, but rather provides factual information that may not be relevant or helpful to the client.
The nurse is not using a therapeutic communication technique, such as reflecting, exploring, or validating the client’s feelings.
Instead, the nurse is shutting down the communication and missing an opportunity to learn more about the client’s concerns and needs.
Choice A is wrong because the nurse is not confronting a painful subject, but rather avoiding it.
The nurse is not acknowledging the client’s fear or inviting the client to talk more about it.
Choice C is wrong because the nurse is not recognizing that the client needs information, but rather assuming that the client does.
The nurse is not asking the client what he or she wants to know about radiation therapy, but rather telling the client what he or she should know.
Choice D is wrong because the nurse is not perceiving that the client is ready to hear more about the treatment, but rather imposing information on the client.
The nurse is not assessing the client’s readiness to learn, but rather giving unsolicited advice.
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