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 A
Explanation
“Since I am taking Clozaril, I will need to have bloodwork performed weekly for six months.” This indicates that the client understands that Clozaril (clozapine) is an antipsychotic medication that can affect the immune system and cause a serious blood disorder called agranulocytosis. The client needs to have regular blood tests to monitor the white blood cell count and prevent infections.
Choice B is wrong because Clozaril can cause urinary retention, not decreased urination. The client should be advised to report any difficulty or pain when urinating.
Choice C is wrong because Clozaril is not a PRN medication. It should be taken regularly as prescribed by the doctor to maintain a therapeutic level and prevent relapse of psychotic symptoms.
Choice D is wrong because Clozaril is not available over the counter or in a generic form. It is a controlled substance that requires a special program and a certified pharmacy to dispense it.
Correct Answer is B
Explanation
The nurse should ask this question to support safe medication administration because the client is to receive medications that are highly teratogenic. Teratogens are substances that can cause congenital disorders and fetal abnormalities.
The nurse should avoid giving teratogenic medications to pregnant clients or clients who may become pregnant.
Choice A is wrong because the family history of cancer is not relevant to the teratogenic effects of the medications.
Choice C is wrong because the previous experience of severe side effects from a drug is not related to the risk of fetal harm.
Choice D is wrong because the allergy to any prescription or non-prescription drugs is not specific to the teratogenic potential of the medications.
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