Practice Question
A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?
Answer Choices:
Correct Answer:
A gastric residual of 300 mL at the end of the shift
Rationale:
🔹A gastric residual volume (GRV) of 300 mL is higher than the generally accepted threshold of 250 mL, and may signal delayed gastric emptying or poor feeding tolerance.
🔹Retaining excessive formula in the stomach increases the risk of aspiration, regurgitation, and feeding intolerance.
🔹Per evidence-based practice, GRV should be assessed every 4–6 hours, and persistent elevations should prompt holding the feeding and notifying the provider.
🔹This helps prevent complications such as aspiration pneumonia.
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This question is from RN Fundamentals 2019 Updated~2023 EXAM which contains 54 questions.
More Questions from This Exam
A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?
Answer Choices:
A. Inserting an NG tube
B. Performing a simple dressing change
C. Evaluating the healing of an incision
D. Changing IV tubing
A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching?
Answer Choices:
A. I will keep my legs crossed while sitting.
B. I should massage my legs when they hurt.
C. I should limit the time that I spend sitting in a chair
D. I will perform leg exercises once every 4 hours while I am awake.
A nurse is documenting client care. Which of the following abbreviations should the nurse use?
Answer Choices:
A. SS for sliding scale
B. OJ for orange juice
C. SQ for subcutaneous
D. BRP for bathroom privileges
A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?
Answer Choices:
A. Recommend small changes for the client to make to change her behavior over time.
B. Assist the client in setting goals to make the change.
C. Develop a plan for the client to integrate the change into her lifestyle.
D. Present information about the benefits of quitting smoking.
A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?
Answer Choices:
A. Heat the formula to 40.50C (1050F).
B. Aspirate residual volume every 4 hr.
C. Flush the tubing with 10 mL of water every 2 hr
D. Change the tubing set every 72 hr.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 4