Free NCLEX-RN Exam Braindumps (page: 159)

Page 159 of 431

When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:

  1. 20 mL
  2. 25 mL
  3. 30 mL
  4. 50 mL

Answer(s): D

Explanation:

(A) A residual volume of 20 mL is not excessive. (B) A residual volume of 25 mL is not excessive. (C) A residual volume of 30 mL is not excessive. (D) Tube feedings should be withheld and physician notified for residual volumes of 50­100 mL.



When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:

  1. 20 mL
  2. 25 mL
  3. 30 mL
  4. 50 mL

Answer(s): D

Explanation:

(A) A residual volume of 20 mL is not excessive. (B) A residual volume of 25 mL is not excessive. (C) A residual volume of 30 mL is not excessive. (D) Tube feedings should be withheld and physician notified for residual volumes of 50­100 mL.



A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, "Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida." At this time the nurse's greatest concern is that:

  1. The client may contract an infection as a result of being exposed to large crowds at spring break
  2. The client does not grasp the full impact of her illness
  3. The client may require transfusion before leaving for spring break
  4. The causative agent be identified and treatment begun

Answer(s): B

Explanation:

(A) The client could contract an infection, but at this point it is not the most pertinent issue. (B) The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. (C) The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. (D) A bone marrow is done first to make a definitive diagnosis; then treatment may begin.



A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, "Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida." At this time the nurse's greatest concern is that:

  1. The client may contract an infection as a result of being exposed to large crowds at spring break
  2. The client does not grasp the full impact of her illness
  3. The client may require transfusion before leaving for spring break
  4. The causative agent be identified and treatment begun

Answer(s): B

Explanation:

(A) The client could contract an infection, but at this point it is not the most pertinent issue. (B) The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. (C) The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. (D) A bone marrow is done first to make a definitive diagnosis; then treatment may begin.



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Naveen Ahlam commented on November 29, 2024
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