A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take?

The correct answer is Choice A - Measure the client's gastric residual before each feeding.

Choice A rationale:

The nurse's first action in caring for a client receiving intermittent enteral feedings should be to measure the client's gastric residual before each feeding. Gastric residual volume helps assess the client's tolerance to enteral feedings and can indicate delayed gastric emptying or potential complications like aspiration. If the residual volume is high, the nurse can collaborate with the healthcare team to determine whether to hold the feeding, adjust the feeding rate, or take other appropriate actions to ensure the client's safety and optimal nutritional status.

Choice B rationale:

Changing the enteral feeding bag and tubing every 24 hours is important to maintain the sterility and integrity of the feeding system. However, it is not the first action the nurse should take. The priority is to assess the client's tolerance to the feeding by measuring gastric residuals, which helps prevent complications.

Choice C rationale:

Documenting intake and output is a crucial aspect of nursing care for all clients, including those receiving enteral feedings. However, in the context of intermittent enteral feedings, measuring gastric residuals before each feeding is a more immediate and specific action to ensure the client's safety and well-being.

Choice D rationale:

Flushing the tubing with 30 mL of water after each feeding is important to prevent clogging and maintain the patency of the enteral feeding tube. However, this action is secondary to measuring gastric residuals, which directly assesses the client's tolerance to the feedings and helps prevent complications.

The correct answer is Choice C: "Do you consume pork products?"

Choice C rationale: Islamic dietary laws, also known as Halal, prohibit the consumption of pork and its by-products. By asking the client about their consumption of pork products, the nurse demonstrates cultural sensitivity and ensures that the client's dietary preferences and religious practices are respected while under the facility's care.

Choice A rationale: Asking the client if they receive Holy Communion is not appropriate, as this practice is associated with Christianity rather than Islam. This question does not effectively address the client's religious preferences or needs in relation to their Islamic faith.

Choice B rationale: Inquiring about adherence to a kosher diet is not relevant, as this dietary practice is specific to Judaism and does not pertain to the Islamic faith. The nurse should be aware of the distinctions between religious practices when providing culturally competent care.

Choice D rationale: There is no general prohibition against blood transfusions in Islam. Islamic teachings generally permit medical treatments, including blood transfusions, when deemed necessary for the well-being and preservation of life. Asking the client about opposition to blood transfusions would not be the most effective way to clarify their religious preferences in the context of Islam.