Nokea
The nurse is caring for a comatose patient who is receiving continuous enteral nutrition through a soft nasogastric tube and notes the presence of new crackles in the patient's lungs. In which order will the nurse take the following actions?
- A. Turn off the tube feeding.
- B. Document assessment findings.
- C. Check the tube feeding residual volume.
- D. Notify the patient's health care provider.
Correct Answer: A,C,D,B
Rationale: The assessment data indicate that aspiration may have occurred, and the nurse's first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the residual volume because it provides data about possible causes of aspiration. The health care provider should be notified and informed of all the assessment data the nurse has just obtained. Lastly, the nurse documents the assessment findings.
You may also like to solve these questions
The nurse is caring for a patient with protein calorie malnutrition who has had abdominal surgery and is receiving parenteral nutrition (PN). Which of the following findings is the best indicator that the patient is receiving adequate nutrition?
- A. Blood glucose is 6.1 mmol/L.
- B. Serum albumin level is 35 g/L.
- C. Fluid intake and output are balanced.
- D. Surgical incision is healing normally.
Correct Answer: D
Rationale: Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient.
The nurse is teaching a patient about a high calorie, high protein diet. Which of the following menu choices indicates that the teaching has been effective?
- A. Baked fish with applesauce
- B. Beef noodle soup and canned corn
- C. Fresh vegetables with yogurt topping
- D. Fried chicken with potatoes and gravy
Correct Answer: D
Rationale: Foods that are high in calories include fried foods and those covered with sauces. High protein foods include meat and dairy products. The other choices are lower in calories and protein.
The nurse receives change-of-shift report about the following four patients. Which of the following patients should the nurse assess first?
- A. A patient who has malnutrition associated with 4+ generalized pitting edema
- B. A patient whose parenteral nutrition has 10 mL of solution left in the infusion bag
- C. A patient whose gastrostomy tube is plugged after crushed medications were given through the tube
- D. A patient who is receiving continuous enteral feedings and has new-onset crackles throughout the lungs
Correct Answer: D
Rationale: The patient data suggest aspiration has occurred and rapid assessment and intervention are needed. The other patients also should be assessed as quickly as possible, but the data about them do not suggest any immediately life-threatening complications.
Which of the following actions should the nurse implement when using a soft, silicone nasogastric tube for enteral feedings?
- A. Avoid giving medications through the feeding tube.
- B. Flush the tubing after checking for residual volumes.
- C. Administer continuous feedings using an infusion pump.
- D. Replace the tube every 3-5 days to avoid mucosal damage.
Correct Answer: B
Rationale: The soft silicone feeding tubes are small in diameter and can easily become clogged unless they are flushed after the nurse checks the residual volume. Either intermittent or continuous feedings can be given. The tubes are less likely to cause mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be replaced at certain intervals. Medications can be given through these tubes, but flushing after medication administration is important to avoid clogging.
The nurse is admitting a patient for electrolyte disorders of unknown etiology. Which of the following findings is most important to report to the health care provider?
- A. The patient's knuckles are macerated.
- B. The patient uses laxatives on a daily basis.
- C. The patient has a history of weight fluctuations.
- D. The patient's serum potassium level is 2.2 mmol/L.
Correct Answer: D
Rationale: The low serum potassium level may cause life-threatening cardiac dysrhythmias and potassium supplementation is needed rapidly. The other information also will be reported because it suggests that bulimia may be the etiology of the patient's electrolyte disturbances, but it does not suggest imminent life-threatening complications.