Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Check gastric residuals every 8 hr.
Checking gastric residuals every 8 hr is not frequent enough, as it can miss signs of delayed gastric emptying, which can cause aspiration, nausea, vomiting, or abdominal distension. Gastric residuals should be checked every 4 hr.
B. Return gastric contents if residual is less than 250 mL.
Returning gastric contents if residual is less than 250 mL is not advisable, as it can increase the risk of infection, contamination, or electrolyte imbalance. Gastric contents should be discarded if residual is more than 100 mL.
C. Measure the pH of gastric residual every 24 hr.
Measuring the pH of gastric residual every 24 hr is not necessary, as it does not reflect the effectiveness or tolerance of the feeding. The pH of gastric residual should be checked before each feeding or every 6 to 8 hr to confirm tube placement and prevent misconnection.
D. Flush the tube with 15 mL of water every 4 hr.
Flushing the tube with 15 mL of water every 4 hr is a correct action, as it can prevent clogging, maintain patency, and clear the tube of formula residue. Water should also be used to flush the tube before and after each medication administration.
This question is an excerpt from Nurse Dive's nursing test bank - RN Nutrition 2019 Nexy Updated 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Checking gastric residuals every 8 hr is not frequent enough, as it can miss signs of delayed gastric emptying, which can cause aspiration, nausea, vomiting, or abdominal distension. Gastric residuals should be checked every 4 hr.
Choice B reason: Returning gastric contents if residual is less than 250 mL is not advisable, as it can increase the risk of infection, contamination, or electrolyte imbalance. Gastric contents should be discarded if residual is more than 100 mL.
Choice C reason: Measuring the pH of gastric residual every 24 hr is not necessary, as it does not reflect the effectiveness or tolerance of the feeding. The pH of gastric residual should be checked before each feeding or every 6 to 8 hr to confirm tube placement and prevent misconnection.
Choice D reason: Flushing the tube with 15 mL of water every 4 hr is a correct action, as it can prevent clogging, maintain patency, and clear the tube of formula residue. Water should also be used to flush the tube before and after each medication administration.
Similar Questions
A nurse is teaching a group of clients about dietary needs to prevent osteoporosis. Which of the following dietary choices should the nurse recommend as having the highest calcium content?
A. 1 cup green grapes
1 cup green grapes has about 15 mg of calcium, which is low compared to other foods. Green grapes are also a good source of vitamin C, potassium, and antioxidants.
B. One medium banana
One medium banana has about 6 mg of calcium, which is very low compared to other foods. Banana is also a good source of potassium, fiber, and vitamin B6.
C. 1 cup broccoli
1 cup broccoli has about 180 mg of calcium, which is high compared to other foods. Broccoli is also a good source of vitamin C, folate, and antioxidants.
D. One large tomato
One large tomato has about 18 mg of calcium, which is low compared to other foods. Tomato is also a good source of vitamin C, lycopene, and potassium.
Full Explanation
Choice A reason: 1 cup green grapes has about 15 mg of calcium, which is low compared to other foods. Green grapes are also a good source of vitamin C, potassium, and antioxidants.
Choice B reason: One medium banana has about 6 mg of calcium, which is very low compared to other foods. Banana is also a good source of potassium, fiber, and vitamin B6.
Choice C reason: 1 cup broccoli has about 180 mg of calcium, which is high compared to other foods. Broccoli is also a good source of vitamin C, folate, and antioxidants.
Choice D reason: One large tomato has about 18 mg of calcium, which is low compared to other foods. Tomato is also a good source of vitamin C, lycopene, and potassium.
A nurse is teaching a group of clients about dietary needs to prevent osteoporosis. Which of the following dietary choices should the nurse recommend as having the highest calcium content?
A. 1 cup green grapes
1 cup green grapes has about 15 mg of calcium, which is low compared to other foods. Green grapes are also a good source of vitamin C, potassium, and antioxidants.
B. One medium banana
One medium banana has about 6 mg of calcium, which is very low compared to other foods. Banana is also a good source of potassium, fiber, and vitamin B6.
C. 1 cup broccoli
1 cup broccoli has about 180 mg of calcium, which is high compared to other foods. Broccoli is also a good source of vitamin C, folate, and antioxidants.
D. One large tomato
One large tomato has about 18 mg of calcium, which is low compared to other foods. Tomato is also a good source of vitamin C, lycopene, and potassium.
Full Explanation
Choice A reason: 1 cup green grapes has about 15 mg of calcium, which is low compared to other foods. Green grapes are also a good source of vitamin C, potassium, and antioxidants.
Choice B reason: One medium banana has about 6 mg of calcium, which is very low compared to other foods. Banana is also a good source of potassium, fiber, and vitamin B6.
Choice C reason: 1 cup broccoli has about 180 mg of calcium, which is high compared to other foods. Broccoli is also a good source of vitamin C, folate, and antioxidants.
Choice D reason: One large tomato has about 18 mg of calcium, which is low compared to other foods. Tomato is also a good source of vitamin C, lycopene, and potassium.
A nurse is teaching a group of clients about risk factors for developing diabetes mellitus. The nurse should include which of the following as a risk factor for diabetes?
A. Abdominal obesity
Abdominal obesity is a risk factor for developing diabetes mellitus. Abdominal obesity, also known as central obesity or visceral fat, is the accumulation of fat around the abdomen and organs. Abdominal obesity can cause insulin resistance, inflammation, and metabolic syndrome, which are all associated with diabetes.
B. Elevated HDL level
Elevated HDL level is not a risk factor for developing diabetes mellitus. HDL stands for high-density lipoprotein, which is a type of cholesterol that carries excess cholesterol from the tissues to the liver for disposal. HDL is also known as "good" cholesterol, as it helps protect against heart disease and stroke. A high HDL level is desirable and beneficial for health.
C. History of hypotension
History of hypotension is not a risk factor for developing diabetes mellitus. Hypotension means low blood pressure, which is usually defined as less than 90/60 mm Hg. Hypotension can cause symptoms such as dizziness, fainting, fatigue, and blurred vision. Hypotension can be caused by dehydration, blood loss, medication side effects, or other conditions.
D. History of hyperthyroidism
History of hyperthyroidism is not a risk factor for developing diabetes mellitus. Hyperthyroidism means overactive thyroid gland, which produces too much thyroid hormone. Thyroid hormone regulates metabolism, growth, and development. Hyperthyroidism can cause symptoms such as weight loss, nervousness, palpitations, heat intolerance, and insomnia. Hyperthyroidism can be caused by Graves' disease, thyroid nodules, or thyroiditis.
Full Explanation
Choice A reason: Abdominal obesity is a risk factor for developing diabetes mellitus. Abdominal obesity, also known as central obesity or visceral fat, is the accumulation of fat around the abdomen and organs. Abdominal obesity can cause insulin resistance, inflammation, and metabolic syndrome, which are all associated with diabetes.
Choice B reason: Elevated HDL level is not a risk factor for developing diabetes mellitus. HDL stands for high-density lipoprotein, which is a type of cholesterol that carries excess cholesterol from the tissues to the liver for disposal. HDL is also known as "good" cholesterol, as it helps protect against heart disease and stroke. A high HDL level is desirable and beneficial for health.
Choice C reason: History of hypotension is not a risk factor for developing diabetes mellitus. Hypotension means low blood pressure, which is usually defined as less than 90/60 mm Hg. Hypotension can cause symptoms such as dizziness, fainting, fatigue, and blurred vision. Hypotension can be caused by dehydration, blood loss, medication side effects, or other conditions.
Choice D reason: History of hyperthyroidism is not a risk factor for developing diabetes mellitus. Hyperthyroidism means overactive thyroid gland, which produces too much thyroid hormone. Thyroid hormone regulates metabolism, growth, and development. Hyperthyroidism can cause symptoms such as weight loss, nervousness, palpitations, heat intolerance, and insomnia. Hyperthyroidism can be caused by Graves' disease, thyroid nodules, or thyroiditis.
