A patient is mechanically ventilated and is receiving enteral nutrition via a nasogastric tube
To help ensure feeding tolerance, the nurse checks residual volumes every 4 hours. During a residual check later in the shift, the nurse aspirates a total residual volume of 350 mL. The nurse will
a. stop the tube feeding, wait 1 hour, and recheck the residual.
b. discontinue the feeding tube and tube feeding and call the physician for TPN orders.
c. continue the tube feeding, if no other gastrointestinal symptoms exist, and reassess the patient with the next residual check.
d. continue the tube feeding and place the patient in the left lateral decubitus position to facilitate gastric emptying.
C
There is little evidence to support a correlation between gastric residual volumes and tolerance to feedings, gastric emptying, and potential aspiration. Except in selected high-risk patients, there is little evidence to support holding tube feedings in patients with gastric residual volumes less than 400 mL.
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The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. If the wound begins to separate after removal of 3 of the 15 staples, the nurse should:
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Which of the following purposes for client documentation, an essential communication tool, is MOST important?
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Which clinical situation is associated with restless leg syndrome? Patients with
a. congestive heart failure c. multiple sclerosis b. stroke d. rheumatoid arthritis
BSA is used to provide accurate dosage calculations specific to the patient's size and severity of
illness. Indicate whether the statement is true or false