The nurse is monitoring the client's ability to tolerate the tube ...

[magmichele12]

The nurse is monitoring the client's ability to tolerate the tube feeding through a new g-tube. The client's gastric residual is currently 315 milliliters.
 
  Which of the following nursing interventions should be performed at this time? (Select all that apply.) 1. Increase the head-of-bed to a 45-degree angle
   2. Change tube feeding setup
   3. Hold tube feeding formula
   4. Add blue food dye to formula
   5. Consider bolus tube feeding

Question 2

The client has come to the clinic for her first prenatal visit. The nurse is assessing her risk for a high-risk pregnancy. Which of the following is a likely result of a high-risk pregnancy?
 
  A) Low birth weight infant C) Constipation
  B) Diabetes insipidus D) High birth weight infant

[jesse.fleming]

Answer to Question 1

1, 3
Rationale: This client has an increased risk of aspirating the tube feeding formula because the gastric residual is greater than 250 milliliters. The nurse should hold the tube feeding and increase the client's head of bed to a 45-degree angle to help prevent aspiration of tube feeding and aspiration pneumonia. The tube feeding setup should be changed each day to help prevent a foodborne illness, but it is not important to change it at this point related to the increased gastric residual. Blue dye should not be added to the tube feeding formula because it can cause skin, organ, and body fluid discoloration and has been associated with death in some patients. Bolus feedings should be avoided because they are associated with an increased risk of aspiration.

Answer to Question 2

A
Feedback:
A high-risk pregnancy is likely to produce a low birth weight infant.

[magmichele12]

YES! Correct, THANKS for helping me on my review

[tkempin]

Excellent