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A nurse is assessing a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following findings should the nurse report to the provider?
- A. Gastric residual of 200 mL
- B. Heart rate of 100/min
- C. Urinary output of 250 mL in 12 hr
- D. Blood glucose level of 180 mg/dL
Correct Answer: D
Rationale: The correct answer is D. A blood glucose level of 180 mg/dL is higher than expected and should be reported to prevent hyperglycemia complications. High blood glucose levels can lead to hyperglycemia, causing various issues such as increased risk of infection and delayed wound healing. Choices A, B, and C are within normal limits for a client receiving continuous enteral feedings and do not require immediate reporting.
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A nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the nurse take?
- A. Check for residual feeding contents.
- B. Administer the feeding through a large-bore syringe.
- C. Flush the tube with 10 mL of water after feeding.
- D. Administer the feeding at room temperature.
Correct Answer: C
Rationale: The correct action for the nurse to take when preparing to administer an intermittent enteral feeding through a nasogastric tube is to flush the tube with 10 mL of water after feeding. This helps maintain tube patency and prevent clogging. Choice A, checking for residual feeding contents, is not the immediate action to take before administering the feeding. Choice B, administering the feeding through a large-bore syringe, is not the recommended method for administering enteral feedings. Choice D, administering the feeding at room temperature, is important but not the immediate action related to tube maintenance.
A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?
- A. Encourage the client to increase dietary fiber.
- B. Maintain the client on a low-residue diet.
- C. Provide the client with frequent high-calorie snacks.
- D. Encourage the client to eat a high-fiber diet.
Correct Answer: B
Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.
A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
- A. Amputation.
- B. Osteoarthritis.
- C. Hypertension.
- D. Primary glaucoma.
Correct Answer: C
Rationale: Hypertension is a contraindication for kidney donation because it can negatively impact the donor's health in the long term. Hypertension poses risks during and after the donation procedure, such as affecting kidney function and potentially leading to complications for both the donor and the recipient. Amputation, osteoarthritis, and primary glaucoma are not direct contraindications for kidney donation and would not typically prevent someone from being a living kidney donor.
A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?
- A. Dehydration is treated with calcium supplements
- B. Dehydration can increase the risk of preterm labor
- C. Dehydration can increase gastroesophageal reflux
- D. Dehydration is caused by a decreased hemoglobin and hematocrit
Correct Answer: B
Rationale: The correct statement the nurse should make is that dehydration can increase the risk of preterm labor. Dehydration reduces amniotic fluid and uterine blood flow, potentially leading to preterm contractions. Choice A is incorrect because dehydration is not treated with calcium supplements but rather with adequate fluid intake. Choice C is incorrect as dehydration does not directly increase gastroesophageal reflux. Choice D is incorrect as dehydration is not caused by decreased hemoglobin and hematocrit levels but rather by insufficient fluid intake or excessive fluid loss.
A nurse is reviewing admission prescriptions for a group of clients. Which prescription should the nurse identify as complete?
- A. Furosemide 20 mg BID
- B. Aspirin 1 tablet daily
- C. Nitroglycerin transdermal patch
- D. Metoprolol 5 mg IV now
Correct Answer: A
Rationale: The correct answer is A. A complete prescription should include the medication name (Furosemide), dosage (20 mg), and administration schedule (BID - twice daily). Choice B is missing the dosage of Aspirin, choice C lacks the dosage information for Nitroglycerin, and choice D does not specify the administration schedule for Metoprolol.