Enteral therapy has been initiated on a client who is now exhibiting nausea and vomiting. Based on this information, what conclusion does the nurse reach regarding the nausea and vomiting?
1. It is caused by irritation of the gastric tube along the stomach serosa.
2. It is caused by an allergic reaction to the feeding.
3. It is caused by the type or amount of feeding.
4. It is caused by a viral agent common to clients with feeding tubes.
Correct Answer: 3
Rationale 1: Irritation of the gastric tube along the stomach serosa is incorrect because the gastric tube does not lie along the serosa.
Rationale 2: An allergic reaction to the feeding is incorrect because while an allergic reaction to the formula might produce these symptoms, the more likely cause is how much and what type of formula the client is receiving.
Rationale 3: Clients sometimes exhibit vomiting, nausea, or diarrhea when first receiving enteral nutrition. Therapy should be started slowly with small quantities so that side effects such as nausea, diarrhea, and vomiting can be assessed.
Rationale 4: A viral agent common to clients with feeding tubes is incorrect because feeding tubes do not make the client more susceptible to viruses.
Global Rationale: Clients sometimes exhibit vomiting, nausea, or diarrhea when first receiving enteral nutrition. Therapy should be started slowly with small quantities so that side effects such as nausea, diarrhea, and vomiting can be assessed. Irritation of the gastric tube along the stomach serosa is incorrect because the gastric tube does not lie along the serosa. An allergic reaction to the feeding is incorrect because while an allergic reaction to the formula might produce these symptoms, the more likely cause is how much and what type of formula the client is receiving. A viral agent common to clients with feeding tubes is incorrect because feeding tubes do not make the client more susceptible to viruses.
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