A client is to receive enteral nutrition. Which information should the nurse provide to the client and family? (SELECT ALL THAT APPLY)

"Enteral nutrition may be used in addition to or instead of oral intake."

"Most enteral nutrition consists of thinned pureed food."

"Enteral nutrition can be given either intermittently or continuously."

"Enteral nutrition is milk based."

"Enteral nutrition can be given through a vein."

Answer and Explanation

Correct Answer : A,C

A. Enteral nutrition can be used when a client is unable to consume adequate nutrition orally or when oral intake is contraindicated. It can be used as a supplement to oral intake or as the sole source of nutrition, depending on the client's condition and nutritional needs.
C. Enteral nutrition can be administered either intermittently, where feedings are given at specific times throughout the day, or continuously, where a steady infusion is delivered over an extended period, typically 16 to 24 hours. The method of administration depends on the client's tolerance, nutritional needs, and clinical condition.
B. Enteral nutrition typically consists of liquid formulas specifically designed to provide complete and balanced nutrition. These formulas come in various formulations, including standard polymeric formulas, high-protein formulas, elemental formulas, and disease-specific formulas. They are not thinned pureed food, which is typically used for clients with dysphagia or swallowing difficulties who are receiving oral feeding.
D. While some enteral nutrition formulas may contain dairy-based ingredients, such as milk protein or lactose, not all enteral formulas are milk-based. There are various types of enteral formulas available, including those that are lactose-free, soy-based, or elemental (containing predigested nutrients), to accommodate different dietary preferences and tolerances.
E. Enteral nutrition is administered directly into the gastrointestinal tract, typically through a feeding tube that is inserted into the stomach or small intestine. It is not given intravenously (through a vein), which would be parenteral nutrition.

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Correct Answer is A

Explanation

A. Infiltration occurs when the intravenous solution leaks into the surrounding tissue instead of flowing into the vein. This can cause discomfort, swelling, and potential tissue damage. Stopping the infusion immediately helps prevent further infiltration and minimizes the risk of complications such as tissue necrosis or damage.
B. While documenting the findings is important for the client's medical record, it is not the first action to take when suspecting infiltration. Immediate intervention to stop the infusion and assess the site for complications takes precedence over documentation.
C. Flushing the catheter with normal saline may be necessary after stopping the infusion to ensure patency and clear any remaining solution from the catheter. However, this step should follow the immediate cessation of the infusion to prevent further infiltration.
D. Removing the catheter may be necessary if significant infiltration has occurred or if there are signs of tissue damage. However, this should be done after stopping the infusion to prevent further infiltration and should be based on the assessment findings and healthcare provider's instructions.

A. pCO2 and pHCO3 and pH are abnormal but the pa02 remains between 80-100 mmHg B. arterial pH & pCO2 are abnormal but the pHCO3 is starting to change C. pCO2, pHCO3 and pH have adjusted in expected range in 72 hours D. arterial pH is between 7.35-7.45 and the pCO2 & pO2 are abnormal

Correct Answer is C

Explanation

C. Full compensation typically occurs within 2 to 3 days (approximately 72 hours) after the onset of an acid-base disturbance. During full compensation, the primary acid-base disorder (e.g., respiratory acidosis or alkalosis, metabolic acidosis or alkalosis) is still present, but the compensatory mechanisms have effectively brought the pH, pCO2, and bicarbonate (pHCO3) levels back towards normal range.
A. Full compensation occurs when both the primary disorder (respiratory or metabolic) and the compensatory mechanism (renal or respiratory) are functioning to return the pH towards normal. In this option, while the pO2 is within the normal range, the pH, pCO2, and bicarbonate (pHCO3) are all abnormal, indicating an ongoing imbalance.
B. Full compensation occurs when all components of the ABG are within or approaching normal range, indicating that the body's compensatory mechanisms have effectively counteracted the primary acid- base disturbance. In this option, the bicarbonate (pHCO3) is mentioned as starting to change, indicating incomplete compensation.
D. While the pH is within the normal range, both the pCO2 and pO2 are abnormal, indicating a primary respiratory disturbance. In the case of full compensation, the pH, pCO2, and bicarbonate (pHCO3) levels would all be within or approaching normal range, indicating that the compensatory mechanisms have effectively counteracted the primary acid-base disturbance.

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A client is to receive enteral nutrition. Which information should the nurse provide to the client and family? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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