The nurse is planning care for the patient receiving nasogastric tube feedings. What reassessment information would best indicate to the nurse that a successful therapeutic regimen has been es-tablished?
a. Respirations are 28 to 32 breaths/min.
b. The residual volume is less than 100 mL.
c. A 4-pound weight loss has occurred over 1 month.
d. Urine output has increased from 10 to 15 mL/hr.
B
A clinical indicator of a successful therapeutic regimen is a residual volume below 100 mL be-cause the nurse understands that this means that the gastric feeding is stimulating the stretch re-ceptors in the stomach to empty gastric contents into the duodenum and precipitate intestinal pe-ristalsis. The peristaltic action moves the formula through the gastrointestinal tract to prevent formula accumulation in the stomach. Tachypnea in a patient with gastric tube feedings warrants further investigation by the nurse because tachypnea is consistent with clinical indicators for as-piration. Significant weight loss that is not the result of decreased fluid volume is consistent with delivering inadequate calories and protein to prevent muscle wasting. The nurse expects urine output between 30 and 50 mL/hr, depending on the patient.
You might also like to view...
A nurse is caring for a patient in the ICU who is recovering from coronary artery bypass graft surgery
Over the course of the next few days, the nurse will be responsible for changing a dressing over the surgical incision site, having the patient change positions in bed, assisting with tracheal suctioning, and assisting with drain removal. The nurse should anticipate that the patient will most likely perceive pain resulting from these procedures in which order, from least painful to most? A) Changing the dressing, position change in bed, tracheal suctioning, drain removal B) Position change in bed, changing the dressing, drain removal, tracheal suctioning C) Drain removal, tracheal suctioning, position change in bed, changing the dressing D) Tracheal suctioning, position change in bed, changing the dressing, drain removal
To ensure learning in the psychomotor domain, which of the following would be most important for the nurse to ensure about the learner?
A) Has a sensory image of how to do the skill B) Has the ability to perform the necessary skill C) Is willing to listen to the information about the skill D) Can continue to practice the skill independently
Viruses can survive only in other living cells
True False
A mentor is meeting with a new nurse and discussing how to incorporate EBP into clinical practice. Which step is essential for this nurse to achieve successful implementation of EBP?
A) Health care institutional review B) Buy-in from the interdisciplinary team C) Client and family support D) Participation of other nurses