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The nurse is preparing to initiate a bolus enteral feedings via nasogastric (NG) tube to a client. Which action represents safe practice by the nurse?
- A. Checking the volume of the residual after administering the bolus feeding
- B. Aspirating gastric contents before initiating the feeding to ensure that pH is greater than 9
- C. Elevating the head of the bed to 25 degrees and maintaining that position for 30 minutes after feeding
- D. Verifying correct nasogastric tube position with aspiration and administration of air bolus with auscultation
Correct Answer: D
Rationale: After initial radiographic confirmation of NG tube placement, methods used to verify nasogastric tube placement include measuring the length of the tube from the point it protrudes from the nose to the end, injecting 10 to 30 mL of air into the tube and auscultating over the left upper quadrant of the abdomen, and aspirating the secretions and checking to see if the pH is less than 3.5 (safest method). Residual should be assessed before administration of the next feeding. Fowler's position is recommended for bolus feedings, if permitted, and should be maintained for 1 hour after instillation.
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The nurse assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate?
- A. Begin administering supplemental oxygen.
- B. Document the findings according to facility policies.
- C. Notify the child's primary health care provider immediately.
- D. Reassess the respiratory rate, rhythm, and depth in 15 minutes.
Correct Answer: B
Rationale: The normal respiratory rate for a 3-year-old child is approximately 20 to 30 breaths per minute. Because the respiratory rate is normal, options 1, 3, and 4 are unnecessary actions. The nurse would document the findings.
The nurse preparing to administer an intermittent tube feeding through a nasogastric (NG) tube assesses for residual volume. How do the resulting data assist in assuring the client's safety?
- A. Confirm proper NG tube placement.
- B. Determine the client's nutritional status.
- C. Evaluate the adequacy of gastric emptying.
- D. Assess the client's fluid and electrolyte status.
Correct Answer: C
Rationale: All stomach contents are aspirated and measured before administering a tube feeding to determine the gastric residual volume. If the stomach fails to empty and propel its contents forward, the tube feeding accumulates in the stomach and increases the client's risk of aspiration. If the aspirated gastric contents exceed the predetermined limit, the nurse withholds the tube feeding and collaborates with the primary health care provider on a plan of care. Assessing gastric residual volume does not confirm placement or assess fluid and electrolyte status. The nurse uses clinical indicators, including serum albumin levels, to determine the client's nutritional status.
A client diagnosed with myxedema reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse plans care knowing that these clinical manifestations are caused by a lack of production of which hormones? Select all that apply.
- A. Thyroxine (T4)
- B. Prolactin (PRL)
- C. Triiodothyronine (T3)
- D. Growth hormone (GH)
- E. Luteinizing hormone (LH)
- F. Adrenocorticotropic hormone (ACTH)
Correct Answer: A,C
Rationale: Although all of these hormones originate from the anterior pituitary, only T3 and T4 are associated with the client's symptoms. Myxedema results from inadequate thyroid hormone levels (T3 and T4). Low levels of thyroid hormone result in an overall decrease in the basal metabolic rate, affecting virtually every body system and leading to weakness, fatigue, and a decrease in heat production. A decrease in LH results in the loss of secondary sex characteristics. A decrease in ACTH is seen in Addison's disease. PRL stimulates breast milk production by the mammary glands, and GH affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.
The nurse in the postpartum unit is assessing for signs of breast-feeding problems demonstrated by either the newborn or the mother. Which findings indicate a problem? Select all that apply.
- A. The infant exhibits dimpling of the cheeks.
- B. The infant makes smacking or clicking sounds.
- C. The mother's breast gets softer during a feeding.
- D. Milk drips from the mother's breast occasionally.
- E. The infant falls asleep after feeding less than 5 minutes.
- F. The infant can be heard swallowing frequently during a feeding.
Correct Answer: A,B,E
Rationale: Infant signs of breast-feeding problems include dimpling of the cheeks; making smacking or clicking sounds; falling asleep after feeding less than 5 minutes; refusing to breast-feed; tongue thrusting; failing to open the mouth at latch-on; turning the lower lip in; making short, choppy motions of the jaw; and not swallowing audibly. Softening of the breast during feeding, noting milk in the infant's mouth or dripping from the mother's breast occasionally, and hearing the infant swallow are signs that the infant is receiving adequate nutrition.
The nurse is preparing to care for a client postureterolithotomy who has a ureteral catheter in place. The nurse should plan to implement which action in the management of this catheter when the client arrives from the recovery room?
- A. Clamp the catheter.
- B. Place tension on the catheter.
- C. Check the drainage from the catheter.
- D. Irrigate the catheter using 10 mL sterile normal saline.
Correct Answer: C
Rationale: Drainage from the ureteral catheter should be checked when the client returns from the recovery room and at least every 1 to 2 hours thereafter. The catheter drains urine from the renal pelvis, which has a capacity of 3 to 5 mL. If the volume of urine or fluid in the renal pelvis increases, tissue damage to the pelvis will result from pressure. Therefore, the ureteral tube is never clamped. Additionally, irrigation is not performed unless there is a specific primary health care provider's prescription to do so.