When the nurse prepares to give a bolus tube feeding to the
patient and determines that the residual gastric content is 150 cc,
her best action is to
a) reassess the residual gastric content in 1 hour.
If the gastric residual exceeds 100 cc 2 hours in a row, the physician
should be notified.
b) notify the physician.
One observation of a residual gastric content over 100 cc does not
have to be reported to the physician. If the observation occurs two
times in succession, the physician should be notified.
c) give the tube feeding.
If the amount of gastric residual exceeds 100 cc, the tube feeding
should be withheld at that time.
d) withhold the tube feeding indefinitely.
If the amount of gastric residual exceeds 100 cc, the tube feeding
should be withheld at that time, but not indefinitely.

1 Answer

Answer :

a) reassess the residual gastric content in 1 hour.
If the gastric residual exceeds 100 cc 2 hours in a row, the physician
should be notified.

Related questions

Description : If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located ... is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Last Answer : a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state ... restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Last Answer : a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log ... by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Last Answer : D. Review endorsement of clients who received Demerol within the last 24 hours

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or ... for short periods of time. Difficulty in waking the patient should be reported or treated immediately.

Last Answer : a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

Description : 30. A T-tube was inserted and the physician ordered, “Monitor the amount, color, consistency and odor of drainage.” Which of the following procedures can the nurse perform without the doctor’s order?

Last Answer : D. Emptying the drainage

Description : When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue ... ) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Last Answer : a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity.

Description : Mercury is typically used in the placement of which of the following tubes? a) Miller-Abbott Most nasoenteric tubes use mercury to carry the tube by gravity to its desired location. b) ... Dobbhoff tubes are used for enteric feeding. d) EnterafloW Enteraflow tubes are used for enteric feeding

Last Answer : a) Miller-Abbott Most nasoenteric tubes use mercury to carry the tube by gravity to its desired location.

Description : Medium -length nasoenteric tubes are used for: a) Feeding Placement of the tube must be verified prior to any feeding. b) Decompression A gastric sump and nasoenteric tube are used for ... aspiration. d) Emptying Gastric sump tubes are used to decompress the stomach and keep it empty.

Last Answer : a) Feeding Placement of the tube must be verified prior to any feeding.

Description : The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Last Answer : A. Gastric decompression

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

Description : When providing care to the patient with bilateral nephrostomy tubes, the nurse never does which of the following? a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a ... saline q8h as ordered The nurse may irrigate a nephrostomy tube with specific orders to do so.

Last Answer : a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a nephrostomy tube because it could cause obstruction and resultant pyelonephritis.

Description : The most significant nursing problem related to continuous tube feedings is a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of ... in fat metabolism and lipoprotein synthesis Tube feedings maintain fat metabolism and lipoprotein synthesis.

Last Answer : a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings.

Description : A patient has had neurologic deficits lasting for more than 24 hours, and now the symptoms are resolving. The nurse concludes that the patient has had which type of stroke? a) Reversible ... and symptoms have stabilized with no indication of further progression of the hypoxic insult to the brain.

Last Answer : a) Reversible ischemic neurologic deficit With a reversible ischemic neurologic deficit, the patient has more pronounced signs and symptoms that last more than 24 hours; symptoms resolve in a matter of days without any permanent neurologic deficit.

Description : The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. ... should avoid exposure to direct sunlight or bright lights for the first five days post-treatment.

Last Answer : a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could ... days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Description : The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not ... blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Last Answer : a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach.

Description : Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest ... finding to the physician immediately. Subcutaneous emphysema results from air entering the tissue planes.

Last Answer : a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

Description : The nurse anticipates that the physician will perform joint aspiration and wrapping with compression elastic dressing for which of the following musculoskeletal problems? a) Joint effusion The described ... of tissue due to insufficient blood supply and may be associated with steroid use.

Last Answer : a) Joint effusion The described treatments are used with joint effusions and hemarthrosis.

Description : To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 - 2 cm and inflammation. The nurse would prepare ... specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Last Answer : B. Ultrasonography

Description : A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Last Answer : A. Write and submit an explanation and reprimand as necessary

Description : After admitting the patient to the PACU, the first action of the nurse would be to A. Assess patency of the airway B. Check the rate of the IV infusion C. Monitor the vital signs D. Assess the clients pain

Last Answer : A. Assess patency of the airway

Description : Bladder retraining following removal of an indwelling catheter begins with instructing the patient to follow a 2-3 hour timed voiding schedule. Immediately after the removal of the indwelling ... in the bladder after voiding, straight catheterization may be performed for complete bladder emptying.

Last Answer : a) encouraging the patient to void immediately. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within two to three hours.

Description : Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs ... pain at the recipient site is anticipated since the wound has been protected by the graft.

Last Answer : a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

Description : The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of ... sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Last Answer : a) Persistent cough Persistent cough may indicate an onset of left-heart failure.

Description : 89. A nurse has to attend a committee meeting for two hours. She delegates her work to another nurse. What primary consideration should be observed?

Last Answer : D. Competency to perform the given function

Description : 78. Nurse Nora is assigned on PM shift for the month of June. She requested the head nurse if she can be on night or morning instead to be able to tutor her 2 sons in the elementary. The head ... it is her turn to go on PM duty. The action of the head nurse exemplifies which of the following?

Last Answer : A. Authority

Description : Mrs. C. Serdenio is currently enrolled in the master's program at the State University and is currently writing her thesis. She applied as a chief nurse in St. John's hospital and ... . the action of the chief nurse constitutes A. Misrepresentation B. Malpractice C. Personification D. Misdemeanor

Last Answer : A. Misrepresentation

Description : Of the following bariatric surgical procedures, which is the best procedure for long-term weight loss? a) Roux-en-Y The Roux-en-Y gastric bypass is the recommended procedure ... This procedure, which resulted in significant complications, has been largely replaced by gastric restriction procedures

Last Answer : a) Roux-en-Y The Roux-en-Y gastric bypass is the recommended procedure for longterm weight loss. In this procedure, a horizontal row of staples creates a stomach pouch with a 1-cm stoma that is anastomosed with a portion of distal jejunum, creating a gastroenterostomy.

Description : Thiopental (sodium thiopental, Thiopentone, STP) characterized by the following except A. Prepares as a pale yellow 10.5 (alkaline) B. After iv bolus, rapidly ... C) Effects include decrease cerebral blood flow and O2 requirements D) Has good analgesic ...

Last Answer : Ans: D

Description : The most common symptom of esophageal disease is a) dysphagia. This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on ... have a variety of causes. d) odynophagia. Odynophagia refers specifically to acute pain on swallowing.

Last Answer : a) dysphagia. This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on swallowing.

Description : Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and ... only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

Last Answer : a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

Description : When the patient has been field triaged and categorized as blue, the nurse recognizes that the patient requires a) fast-track or psychological support. When a patient is categorized as blue, field ... . d) urgent care. Field triaged patients who require urgent care will be categorized as green.

Last Answer : a) fast-track or psychological support. When a patient is categorized as blue, field triage has identified fasttrack or psychological support needs.

Description : If a case of smallpox is suspected, the nurse should a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office ... very different from that of chickenpox. With chickenpox, lesions appear at different developmental stages.

Last Answer : a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office at 770-488-7100. The CDC will respond by immmediate provision ... with negative pressure, and maintain thorough lists of all those who have contact with the patient.

Description : The nurse teaches the parent of the child with chickenpox that the child is no longer contagious to others when a) the vesicles and pustules have crusted. When the lesions have crusted, the ... , and pustules appear. The child remains contagious when the rash is changing into vesicles and pustules.

Last Answer : a) the vesicles and pustules have crusted. When the lesions have crusted, the patient is no longer contagious to others.

Description : The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in ... severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

Last Answer : a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

Description : When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse ... heterotrophic ossification. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

Last Answer : a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

Description : The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out ... alcohol and caffeine consumption in moderation, and performing a regular weight-bearing exercise regimen.

Last Answer : a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise ... and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Description : When the nurse notes that the patient's left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) ... the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Last Answer : a) hallux valgus. Hallux valgus is commonly referred to as a bunion.

Description : The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin ... A broken cast should be reported to the physician; the patient should not attempt to fix it.

Last Answer : a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems. Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems; do not cover it with plastic or rubber.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the ... are removed routinely. Traction must be continuous to be effective in reducing and immobilizing fractures.

Last Answer : a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

Description : Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to ... the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Last Answer : a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes.

Description : Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation ... The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Last Answer : a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve.

Description : The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to ... output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Last Answer : a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.