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The nurse has placed a feeding tube for a client with a gastroesophageal disorder. What recommendation(s) should the nurse follow to confirm proper placement of the tube? Select all that apply.
- A. Observe for respiratory distress.
- B. Measure pH of feeding tube aspirates.
- C. Auscultate.
- D. Monitor aspirate for sudden change in amount.
- E. Mark the tube at the exit site.
- F. Obtain radiographic confirmation.
Correct Answer: A,B,D,E,F
Rationale: The nurse should observe for respiratory distress, measure the pH of feeding tube aspirates, monitor the aspirate for a sudden change in the amount, and mark the tube at the exit site after radiographic confirmation and then use the marker to ensure that the correct location is maintained during use. Auscultation should not be used to determine location, because this is not a valid way to confirm tube placement.
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An older adult client presents with a complaint of 10-lb weight loss over the past month. Which assessment finding is most important in determining the care of this client?
- A. History of seasonal allergies
- B. History gallbladder removal
- C. History of COPD
- D. History of osteoarthritis
Correct Answer: C
Rationale: Decreased appetite may be a result of diminished oxygenation to the appetite centers of the brain. With a history of chronic obstructive pulmonary disease, oxygen deprivation may be occurring, and this is a starting assessment for this client. Seasonal allergies can aggravate breathing difficulties but are not as significant as COPD. Removal of the gallbladder is not indicated in current weight loss issues. Osteoarthritis may make it more difficult for the client to shop for food but not is as significant as oxygen deprivation.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply.
- A. Encourage the client to eat frequent, small, well-balanced meals.
- B. Inform the client to remain upright for at least 2 hours after meals.
- C. Encourage the client to eat later in the day before bedtime rather than early in the morning.
- D. Instruct the client to avoid alcohol or tobacco products.
- E. Instruct the client to eat slowly and chew the food thoroughly.
Correct Answer: A,B,D,E
Rationale: The nurse should encourage the client to eat frequent, small, well-balanced meals, inform the client to remain upright for at least 2 hours after meals, instruct the client to avoid alcohol or tobacco products, and instruct the client to eat slowly and chew the food thoroughly when teaching the client how to reduce reflux. The nurse should discourage the client from eating before bedtime.
The nurse is preparing to administer ondansetron to an older adult client. Which safety warning(s) should the nurse consider when administering the medication? Select all that apply.
- A. Do not use if the client has a heart block or prolonged QT interval.
- B. Increases sedation if used with opiates.
- C. Emphasize prevention. The client must take consistently to prevent nausea and vomiting.
- D. Explain that it must be started before travel to be effective.
- E. Explain that there is a risk for dehydration.
Correct Answer: A,B,C
Rationale: When administering ondansetron to an older adult client, the nurse should take extra care to consider safety warnings that advise the nurse to avoid use if a client has a heart block or prolonged QT interval, and should also be mindful that the medication can increase sedation when used with opiates. In addition, the nurse should adhere to guidelines instructing an emphasis on prevention for the client, the older adult client must take the medication consistently to prevent nausea and vomiting. Ondansetron is not given to relieve motion sickness; therefore, beginning the medication before travel is not applicable. Prochlorperazine, not ondansetron, may increase dehydration in older adults.
The nurse is caring for a client with hypovolemia related to prolonged vomiting and decreased intake of oral fluids. What activity(ies) should the nurse include in the client's plan of care? Select all that apply.
- A. Encourage the client to drink a 16 oz (480 mL) glass of water over the course of 15 minutes.
- B. Instruct the client to avoid beverages with additives such as electrolytes.
- C. Inform the primary provider if urine output is 3.5 oz (100 mL) per day or lower.
- D. Monitor weight daily.
- E. Assess skin turgor and mucous membranes.
Correct Answer: D,E
Rationale: The nurse should monitor the client's weight daily and assess skin turgor and mucous membranes. The nurse should offer clear liquids in small amounts. Slow introduction of fluids enables the client to develop tolerance and determine if it is possible to advance the diet. The nurse should recommend the use of commercial, over-the-counter beverages that contain electrolytes. If the client's urine output drops below 17 oz (500 mL) per day, the nurse should notify the primary provider because this indicates severe dehydration and the need for IV replacement fluids.
The nurse is caring for a client with anorexia and constipation due to reduced bulk in the diet and the use of liquid supplements. Which intervention(s) should the nurse include in the plan of care for the client? Select all that apply.
- A. Keep a record of the client's bowel movements.
- B. Consult with the health care provider and dietitian about changing the type of supplement.
- C. Dilute the formula until the client adjusts to the concentrated contents.
- D. Administer a prescribed stool softener.
- E. Assist the client and dietitian to decrease dietary fiber.
Correct Answer: A,B,C,D
Rationale: The nurse should keep a record of the client's bowel movements, consult with the health care provider and dietitian about changing the type of supplement, dilute the formula until the client adjusts to the concentrated contents, and administer a prescribed stool softener. Dietary fiber should be increased, not decreased, as a decrease will further reduce the amount of bulk in the client's diet and contribute to further constipation.