The nurse notes that a client receiving enteral feedings has a residual volume of 315 mL. Which action should the nurse take?
a. Hold tube feeding formula
b. Change tube feeding setup
c. Add blue food dye to formula
d. Increase the head-of-bed to a 45-degree angle
d. Increase the head-of-bed to a 45-degree angle
This client has an increased risk of aspirating the tube feeding formula because of the large gastric residual volume. The head of the bed should be increased to a 45-degree angle to reduce the risk of aspiration. Holding tube feedings for residuals < 500 mL are not advised. 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.
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Group therapy, which assists in relieving emotional distress and encourages psychological and behavioral changes, was developed following World War II as a result of a:
a. Study of the benefits of group therapy b. Decreasing number of mental health facilities c. Shortage of psychiatrists d. Grant from the federal government
Where are most uncomplicated UTIs acquired?
A) Hospital B) Community C) Through sexual intercourse D) Nosocomial
The nurse is assessing an older adult patient for depression. Which is an atypical clinical manifestation that occurs with depression for the older adult patient?
1) Social withdrawal 2) Memory changes 3) Hostility 4) Agitation
The nurse is practicing the concept of holism with a client. Which action is the nurse most likely making?
1. Considering how the loss of a client's job will affect the regulation of the client's diabetes 2. Making sure to do complete teaching regarding pharmacological interventions 3. Following physician treatments on schedule 4. Prioritizing the needs of the client assigned according to Maslow's hierarchy