A nurse is caring for a client who is receiving a continuous enteral tube feeding and reports cramping and abdominal distention. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take is option A: Check for gastric residual. When a client on continuous enteral feeding experiences cramping and distention, it is essential to assess for gastric residual volume to determine if the client is tolerating the feeding adequately. High residual volumes can indicate feeding intolerance, possibly leading to abdominal discomfort and distention. Option B: Applying low intermittent suction is not appropriate in this situation as it is typically used for nasogastric tube decompression, not for assessing feeding tolerance. Option C: Increasing the rate of the feeding is contraindicated when the client is already experiencing symptoms of feeding intolerance as it can worsen the situation. Option D: Requesting a higher-fat formula is not the immediate action needed when the client is experiencing cramping and abdominal distention. Checking for gastric residual will provide crucial information to guide further interventions. Educationally, understanding the importance of monitoring gastric residual volumes in clients on enteral feedings is crucial for nurses caring for patients with altered nutritional needs. It helps in assessing the adequacy of the feeding regimen and preventing complications related to feeding intolerance. Regular assessment and appropriate interventions based on findings are key components of safe and effective enteral feeding management.

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to take first is option D: Disconnect the tube from the suction source. This is crucial because before removing the clogged NG tube, it is essential to first disconnect it from the suction source to prevent injury or aspiration of gastric contents into the lungs during removal. Option A, assisting the client to blow her nose, is incorrect as it is not a necessary step in the process of removing a clogged NG tube. Option B, asking the client to take a deep breath and hold it, is also incorrect as it does not address the immediate safety concern of disconnecting the tube from the suction source. Option C, pinching the proximal end of the tube, is incorrect as well because this step should be taken after disconnecting the tube from the suction source to prevent spillage of gastric contents. In an educational context, it is important for nurses to understand the proper sequence of steps when dealing with NG tubes to ensure patient safety and prevent complications. Emphasizing the correct order of actions in scenarios like tube removal can help nurses provide effective and safe care to their patients.

Correct Answer: C

Rationale: In this scenario, the nurse should recommend graham crackers as the appropriate snack choice for the 9-month-old infant. Graham crackers are a suitable option due to their soft texture, which makes them easy for the infant to chew and swallow, reducing the risk of choking. They are also low in sugar and salt, which aligns with the dietary recommendations for infants to avoid added sugars and salt. Additionally, graham crackers provide carbohydrates for energy, which is important for the growing needs of infants. The other options can be considered inappropriate choices for a 9-month-old infant for various reasons. Skim milk is not recommended as a snack choice for infants under the age of one, as it does not provide the necessary nutrients and can be difficult for infants to digest. Unsalted popcorn poses a choking hazard due to its hard texture, which can be challenging for infants to chew. Raw carrots are also a choking hazard for young infants because of their firm texture. Educationally, this question highlights the importance of selecting age-appropriate and safe food choices for infants. It emphasizes the need for healthcare providers to educate parents on suitable snacks that meet the nutritional requirements and safety considerations for infants at different developmental stages. By understanding the rationale behind the correct choice and the risks associated with the incorrect options, healthcare professionals can better support parents in promoting healthy eating habits for their infants.

Correct Answer: C

Rationale: In this scenario, the correct answer is "C) Cramping." When a client is lactose intolerant, it means their body cannot properly digest lactose, a sugar found in milk and dairy products. As a result, when they consume lactose-containing foods, they may experience symptoms like cramping, bloating, gas, and diarrhea. Option A) Fever is not typically a direct symptom of lactose intolerance but may occur if there is an underlying infection or inflammatory process. Option B) Blood in stools is not a common symptom of lactose intolerance. It is more indicative of conditions like gastrointestinal bleeding or inflammatory bowel disease. Option D) Steatorrhea, which refers to fatty, greasy stools, is not a typical symptom of lactose intolerance but is more commonly associated with conditions affecting fat digestion and absorption. Educationally, understanding the clinical manifestations of lactose intolerance is crucial for nurses to provide appropriate care and education to clients with this condition. Recognizing these symptoms can help in making dietary recommendations and managing discomfort for lactose-intolerant individuals.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B: Request that coffee is removed from meal trays. The Seventh-Day Adventist dietary laws prohibit the consumption of coffee and other stimulants. By excluding coffee from the client's meal tray, the nurse respects and supports the client's religious dietary preferences. Option A, replacing salt with pepper when seasoning water, is incorrect as it does not align with Seventh-Day Adventist dietary laws. While reducing salt intake is generally a healthy practice, it is not a specific requirement of this particular dietary guideline. Option C, offering pork with two meals per week, is also incorrect. Pork is typically not consumed by individuals following Seventh-Day Adventist dietary laws, as it is considered unclean according to their beliefs. Option D, providing a high-protein snack between meals, is not directly related to Seventh-Day Adventist dietary laws. While protein intake is important for overall health, it is not a specific requirement outlined in this dietary guideline. Educationally, this question highlights the importance of respecting and accommodating clients' cultural and religious beliefs when planning their care, including their dietary preferences. Understanding and adhering to these guidelines can enhance the nurse-client relationship and contribute to the client's overall well-being and satisfaction with their care.