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A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?
- A. Measure the client's gastric residual every 12 hours.
- B. Obtain the client's electrolyte levels every 4 hours.
- C. Keep the client's head elevated at 15° during feedings.
- D. Flush the client's tube with 30 mL of water every 4 hours.
Correct Answer: D
Rationale: Flushing the client's tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client's gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client's electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client's head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.
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A nurse is teaching a parent about appropriate snack choices for her 9-month-old infant. Which of the following food choices should the nurse recommend?
- A. Skim milk
- B. Unsalted popcorn
- C. Graham crackers
- D. Raw carrots
Correct Answer: C
Rationale: Graham crackers are an appropriate snack choice for a 9-month-old infant due to their texture and ease of consumption. Skim milk (Choice A) is not recommended for infants under 1 year old due to the potential risk of developing milk allergies. Unsalted popcorn (Choice B) can be a choking hazard for infants. Raw carrots (Choice D) are a potential choking hazard for a 9-month-old infant and may be difficult for them to chew and digest.
A nurse is teaching a client about complete and incomplete proteins. Which of the following foods should the nurse include in the teaching as an incomplete protein?
- A. 4 oz chickpeas
- B. 2 poached eggs
- C. 2 oz cheddar cheese
- D. 4 oz salmon fillet
Correct Answer: A
Rationale: The correct answer is A: 4 oz chickpeas. Chickpeas are considered an incomplete protein because they lack one or more essential amino acids required by the body. Incomplete proteins do not provide all essential amino acids in sufficient quantities. Choice B, 2 poached eggs, is a complete protein source because eggs contain all essential amino acids. Choice C, 2 oz cheddar cheese, is also a complete protein as it contains all essential amino acids. Choice D, 4 oz salmon fillet, is another complete protein source as fish typically provide all essential amino acids needed by the body.
A healthcare professional is reviewing the laboratory findings of a client who has heart failure. Which of the following findings indicates that the client is experiencing fluid volume excess?
- A. BUN 8 mg/dL
- B. Hgb 15 g/dL
- C. Creatinine 0.8 mg/dL
- D. Sodium 140 mEq/L
Correct Answer: A
Rationale: A BUN level of 8 mg/dL indicates fluid volume excess in a client with heart failure. BUN (Blood Urea Nitrogen) levels can be low in fluid overload due to hemodilution, a common occurrence in heart failure. High levels of BUN usually indicate dehydration or impaired renal function, which are not the case in fluid volume excess. Choices B, C, and D are within normal ranges and do not specifically indicate fluid volume excess.
A nurse is preparing to administer a gavage feeding via a nasogastric tube to a preterm newborn who is receiving supplemental oxygen. Which of the following actions should the nurse take?
- A. Stabilize the tube with tape to the newborn's cheek.
- B. Remove supplemental oxygen during the feeding.
- C. Measure the stomach aspirate prior to the feeding.
- D. Place the newborn on their left side for 30 minutes after the feeding.
Correct Answer: C
Rationale: Measuring the stomach aspirate prior to the feeding is crucial to ensure the correct placement and function of the nasogastric tube. This step helps prevent complications such as aspiration or improper feeding. Choice A is incorrect as stabilizing the tube with tape to the newborn's cheek can cause discomfort and skin irritation. Choice B is incorrect because removing supplemental oxygen during the feeding may compromise the newborn's respiratory status. Choice D is incorrect because placing the newborn on their left side for 30 minutes after the feeding is not a standard practice and is unnecessary for administering gavage feeding.
A client is planning eating strategies with a nurse who has nausea from equilibrium imbalance. Which of the following strategies should the nurse recommend?
- A. Encourage the client to eat, even if nauseated.
- B. Provide low-fat carbohydrates with meals.
- C. Limit fluid intake between meals.
- D. Serve hot foods at mealtime.
Correct Answer: B
Rationale: The correct answer is B: Provide low-fat carbohydrates with meals. Low-fat carbohydrates are easier to digest and can help manage nausea without overloading the digestive system. Encouraging the client to eat even if nauseated (Choice A) may worsen their symptoms. Limiting fluid intake between meals (Choice C) may lead to dehydration, which can exacerbate nausea. Serving hot foods at mealtime (Choice D) may not necessarily address the underlying issue of equilibrium imbalance causing nausea.