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NurseDive Free Nursing Practice Question
A charge nurse observes a nurse administer intermitent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?
A. The nurse irrigates the NG tube with tap water after feeding.
Choice A reason: This is incorrect. Irrigating the NG tube with tap water after feeding is an acceptable practice, unless the client is immunocompromised or has fluid restrictions. Tap water can help flush out any residual formula and prevent clogging of the tube.
B. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
Choice B reason: This is incorrect. Initiating the feeding after aspirating 50 mL of gastric residual is an acceptable practice, unless the facility has a different protocol. Gastric residual volume (GRV) is the amount of fluid left in the stomach before feeding. A GRV of less than 250 mL indicates that the stomach is emptying properly and that the client can tolerate the feeding.
C. The nurse administers the feeding through a syringe barrel by gravity.
Choice C reason: This is incorrect. Administering the feeding through a syringe barrel by gravity is an acceptable practice, unless the client has a history of aspiration or intolerance to bolus feedings. Gravity feedings are faster and easier than pump feedings, but they require careful monitoring of the flow rate and the client's response.
D. The nurse allows the client to rest in a supine position during feeding.
Choice D reason: This is the correct answer. Allowing the client to rest in a supine position during feeding is a dangerous practice that can cause aspiration, pneumonia, or death. The nurse should elevate the head of the bed at least 30 degrees during and for at least one hour after feeding. This can help prevent regurgitation and aspiration of the formula into the lungs.
This question is an excerpt from Nurse Dive's nursing test bank - NY BSN Proctored Exam. Take the full exam now
Similar Questions
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition?
A. Drinks green tea
Choice A reason: This is incorrect. Drinking green tea is not a risk factor for peptic ulcer. Green tea contains antioxidants and polyphenols that may have anti-inflammatory and protective effects on the gastric mucosa. However, green tea also contains caffeine, which can stimulate gastric acid secretion and aggravate ulcer symptoms. Therefore, the nurse should advise the client to limit or avoid caffeine intake.
B. History of bulimia
Choice B reason: This is incorrect. History of bulimia is not a risk factor for peptic ulcer. Bulimia is an eating disorder characterized by binge eating and purging behaviors, such as vomiting, laxative use, or excessive exercise. Bulimia can cause damage to the esophagus, teeth, and mouth, but it does not directly affect the stomach or duodenum, where peptic ulcers occur.
C. History of NSAID use
Choice C reason: This is the correct answer. History of NSAID use is a risk factor for peptic ulcer. NSAIDs are nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, or naproxen, that are used to treat pain, inflammation, or fever. NSAIDs can inhibit the production of prostaglandins, which are substances that protect the gastric mucosa from acid and injury. NSAIDs can also increase gastric acid secretion and reduce blood flow to the stomach. These effects can cause erosion and ulceration of the gastric mucosa.
D. Has a glass of wine with dinner each day
Choice D reason: This is incorrect. Having a glass of wine with dinner each day is not a risk factor for peptic ulcer. Moderate alcohol consumption (one drink per day for women and two drinks per day for men) may have some health benefits, such as reducing the risk of cardiovascular disease or diabetes. However, excessive alcohol consumption (more than three drinks per day) can irritate and damage the gastric mucosa and increase the risk of peptic ulcer and bleeding. Therefore, the nurse should advise the client to limit or avoid alcohol intake.
A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the
nurse include in the teaching?
A. Bear down hard when defecating.
Choice A reason: This is incorrect. Bearing down hard when defecating can cause straining, which can worsen constipation and increase the risk of hemorrhoids, anal fissures, or rectal prolapse. The nurse should advise the client to relax and avoid straining when defecating.
B. Limit activity.
Choice B reason: This is incorrect. Limiting activity can reduce bowel motility and contribute to constipation. The nurse should encourage the client to increase physical activity, such as walking, swimming, or cycling, to stimulate bowel movements and improve overall health.
C. Increase dietary intake of raw vegetables.
Choice C reason: This is the correct answer. Increasing dietary intake of raw vegetables can help prevent and treat constipation. Raw vegetables are rich in fiber, which can add bulk and softness to the stool and make it easier to pass. The nurse should recommend the client to eat at least 25 grams of fiber per day from various sources, such as fruits, grains, nuts, seeds, and legumes.
D. Drink four to five glasses of water daily.
Choice D reason: This is incorrect. Drinking four to five glasses of water daily may not be enough to prevent or treat constipation. Water can help hydrate the stool and make it softer and easier to pass. However, the amount of water needed varies depending on the individual's age, weight, activity level, and health status. The nurse should advise the client to drink enough water to keep the urine clear or pale yellow and to avoid dehydration. The nurse should also caution the client to limit or avoid caffeinated or alcoholic beverages, which can have a diuretic effect and cause fluid loss.
A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse
include in the plan?
A. Sliced ham with green salad
Choice A reason: This is incorrect. Sliced ham with green salad is not a good menu selection for a client who has diverticulitis. Ham is high in fat and salt, which can irritate the digestive tract and worsen inflammation. Green salad contains raw vegetables, which are high in fiber and can increase bowel movements and pressure on the diverticula. Diverticula are small pouches that form in the wall of the colon and can become inflamed or infected.
B. Grilled chicken breast with white rice
Choice B reason: This is the correct answer. Grilled chicken breast with white rice is a good menu selection for a client who has diverticulitis. Chicken breast is low in fat and high in protein, which can promote healing and prevent malnutrition. White rice is low in fiber and easy to digest, which can reduce bowel movements and pressure on the diverticula.
C. Pork tenderloin with green peas
Choice C reason: This is incorrect. Pork tenderloin with green peas is not a good menu selection for a client who has diverticulitis. Pork tenderloin is high in fat, which can irritate the digestive tract and worsen inflammation. Green peas are high in fiber and contain seeds, which can increase bowel movements and pressure on the diverticula and cause them to rupture or bleed.
D. Turkey sandwich with celery sticks
Choice D reason: This is incorrect. Turkey sandwich with celery sticks is not a good menu selection for a client who has diverticulitis. Turkey sandwich may contain bread, cheese, or mayonnaise, which are high in fat and can irritate the digestive tract and worsen inflammation. Celery sticks are high in fiber and contain strings, which can increase bowel movements and pressure on the diverticula and cause them to rupture or bleed.
E. Turkey sandwich with celery sticks