Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?
A. Obtain the client's electrolyte levels every 4 hr.
While monitoring electrolyte levels is important, obtaining them every 4 hours is excessive for a client who is stable and just starting enteral feedings. Typically, electrolyte levels are monitored based on clinical condition and provider orders.
B. Keep the client's head elevated at 15° during feedings.
The client's head should be elevated at least 30 to 45 degrees during enteral feedings to reduce the risk of aspiration and improve gastric emptying. A position of only 15 degrees is insufficient for safety.
C. Measure the client's gastric residual every 12 hr.
Gastric residuals should be assessed more frequently, especially in the initial stages of enteral feeding. It is typically recommended to check gastric residuals every 4 to 6 hours to ensure proper gastric emptying and tolerance to the feedings.
D. Flush the client's tube with 30 mL of water every 4 hr.
Flushing the tube with water every 4 hours is a standard practice to maintain tube patency, prevent clogging, and ensure that the client receives adequate hydration.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Nutrition 2019 Proctored Exam. Take the full exam now
Full Explanation
A. Obtain the client's electrolyte levels every 4 hr. While monitoring electrolyte levels is important, obtaining them every 4 hours is excessive for a client who is stable and just starting enteral feedings. Typically, electrolyte levels are monitored based on clinical condition and provider orders.
B. Keep the client's head elevated at 15° during feedings. The client's head should be elevated at least 30 to 45 degrees during enteral feedings to reduce the risk of aspiration and improve gastric emptying. A position of only 15 degrees is insufficient for safety.
C. Measure the client's gastric residual every 12 hr. Gastric residuals should be assessed more frequently, especially in the initial stages of enteral feeding. It is typically recommended to check gastric residuals every 4 to 6 hours to ensure proper gastric emptying and tolerance to the feedings.
D. Flush the client's tube with 30 mL of water every 4 hr. Flushing the tube with water every 4 hours is a standard practice to maintain tube patency, prevent clogging, and ensure that the client receives adequate hydration.
Similar Questions
A nurse is planning dietary teaching for a client who adheres to a vegan diet. The nurse should identify that the client is at greatest risk for which of the following nutrient deficiencies?
A. Omega-3 fatty acids
Omega-3 fatty acids, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are mainly found in fatty fish. Since vegans avoid animal products, they may not consume adequate amounts of EPA and DHA. Plant-based sources of omega-3 fatty acids, such as flaxseeds, chia seeds, and walnuts, provide a different type of omega-3 called alpha-linolenic acid (ALA), which can be converted to EPA and DHA in the body to some extent. However, this conversion is not very efficient, and the amount of EPA and DHA obtained from plant-based sources may be insufficient to meet the body's needs. Therefore, vegan individuals are at greater risk of omega-3 fatty acid deficiency.
B. Magnesium
Magnesium, potassium, and vitamin A deficiencies are not specifically associated with a vegan diet. These nutrients can be obtained from various plant-based sources. Magnesium can be found in foods such as legumes, nuts, seeds, whole grains, and leafy green vegetables.
C. Potassium
Potassium is abundant in fruits, vegetables, legumes, and whole grains.
D. Vitamin A
Vitamin A can be obtained from plant-based sources like carrots, sweet potatoes, spinach, and other dark leafy greens. However, it is important for individuals following a vegan diet to ensure they consume a varied and balanced diet to meet their nutritional needs for these and other essential nutrients.
Full Explanation
Omega-3 fatty acids, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are mainly found in fatty fish. Since vegans avoid animal products, they may not consume adequate amounts of EPA and DHA. Plant-based sources of omega-3 fatty acids, such as flaxseeds, chia seeds, and walnuts, provide a different type of omega-3 called
alpha-linolenic acid (ALA), which can be converted to EPA and DHA in the body to some extent. However, this conversion is not very efficient, and the amount of EPA and DHA obtained from plant-based sources may be insufficient to meet the body's needs. Therefore, vegan individuals are at greater risk of omega-3 fatty acid deficiency.
Magnesium, potassium, and vitamin A deficiencies are not specifically associated with a vegan diet. These nutrients can be obtained from various plant-based sources. Magnesium can be found in foods such as legumes, nuts, seeds, whole grains, and leafy green vegetables.
Potassium is abundant in fruits, vegetables, legumes, and whole grains.
Vitamin A can be obtained from plant-based sources like carrots, sweet potatoes, spinach, and other dark leafy greens. However, it is important for individuals following a vegan diet to ensure they consume a varied and balanced diet to meet their nutritional needs for these and other essential nutrients.
A nurse is assessing a client who is recovering from a stroke. Which of the following findings is a manifestation of dysphagia?
A. Weight gain
Weight gain is not a typical manifestation of dysphagia. If dysphagia is severe and leads to food avoidance or restricted intake, weight loss may occur instead.
B. Continuous smiling
Continuous smiling is not a specific manifestation of dysphagia. It may be seen in some stroke survivors as a result of changes in facial muscle control, such as facial weakness or spasticity. However, it is not directly related to dysphagia.
C. Hoarse voice
Dysphagia refers to difficulty or discomfort in swallowing. It can occur as a result of weakened or impaired muscles involved in swallowing, which is common after a stroke. When dysphagia is present, it can affect the function of the vocal cords and lead to changes in voice quality, including hoarseness. The hoarseness may be due to the entry of food or liquid into the airway during swallowing, causing irritation to the vocal cords.
D. Expressive aphasia
Expressive aphasia refers to difficulty expressing thoughts or using language effectively. It is a common language impairment that can occur after a stroke, specifically affecting the ability to produce or articulate words and sentences. While it is a communication difficulty, it is not directly related to dysphagia, which specifically refers to difficulty swallowing.
Full Explanation
Dysphagia refers to difficulty or discomfort in swallowing. It can occur as a result of weakened or impaired muscles involved in swallowing, which is common after a stroke. When dysphagia is present, it can affect the function of the vocal cords and lead to changes in voice quality, including hoarseness. The hoarseness may be due to the entry of food or liquid into the airway during swallowing, causing irritation to the vocal cords.
Weight gain is not a typical manifestation of dysphagia. If dysphagia is severe and leads to food avoidance or restricted intake, weight loss may occur instead.
Continuous smiling is not a specific manifestation of dysphagia. It may be seen in some stroke survivors as a result of changes in facial muscle control, such as facial weakness or spasticity. However, it is not directly related to dysphagia.
Expressive aphasia refers to difficulty expressing thoughts or using language effectively. It is a common language impairment that can occur after a stroke, specifically affecting the ability to produce or articulate words and sentences. While it is a communication difficulty, it is not directly related to dysphagia, which specifically refers to difficulty swallowing.
A nurse is teaching the family of a school-age child who is obese about complications of childhood obesity. Which of the following complications should the nurse include in the teaching?
A. Juvenile rheumatoid arthritis
Juvenile rheumatoid arthritis is an autoimmune condition characterized by joint inflammation in children. While obesity can place additional stress on joints, it is not directly linked to the development of juvenile rheumatoid arthritis.
B. Type 1 diabetes mellitus
Type 1 diabetes mellitus is an autoimmune condition where the body's immune system mistakenly attacks and destroys insulin-producing cells in the pancreas. Obesity is not a known cause of type 1 diabetes.
C. Hypothyroidism
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone. While obesity can be associated with thyroid disorders, such as hypothyroidism, it is not a direct complication of childhood obesity.
D. Hypertension
Childhood obesity is associated with an increased risk of developing various health problems, and hypertension is one of the most common complications. Excess weight and adiposity can lead to increased blood volume and systemic inflammation, which can contribute to the development of hypertension. Long-standing hypertension in childhood can increase the risk of cardiovascular disease and other health issues later in life.
Full Explanation
Childhood obesity is associated with an increased risk of developing various health problems, and hypertension is one of the most common complications. Excess weight and adiposity can lead to increased blood volume and systemic inflammation, which can contribute to the development of hypertension. Long-standing hypertension in childhood can increase the risk of cardiovascular disease and other health issues later in life.
The other options are incorrect:
Juvenile rheumatoid arthritis is an autoimmune condition characterized by joint inflammation in children. While obesity can place additional stress on joints, it is not directly linked to the development of juvenile rheumatoid arthritis.
Type 1 diabetes mellitus is an autoimmune condition where the body's immune system mistakenly attacks and destroys insulin-producing cells in the pancreas. Obesity is not a known cause of type 1 diabetes.
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone. While obesity can be associated with thyroid disorders, such as hypothyroidism, it is not a direct complication of childhood obesity.